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Title: 200-HOUSEKEEPING

Fields marked with an asterisk (*) must be filled out before submitting.

Name (Last,First Middle *

Contact Details

Address *
City *
State *
ZIP
Contact Phone *
Contact 2 Phone
Other Phone
Email
If you are under 18, and it is required, can you furnish a work permit? Yes
No
If no, explain:
Have you been employed here before? * Yes
No
If so, when and in what capacity?
Are you legally eligible for employment in the United States? Yes
No
Date available to work
Are you able to meet the attendance requirements for this position? Yes
No
Have you ever been convicted of a crime? * Yes
No
If Yes Explain:

Employment History

(1).

Date Started
Date Ended
Employer
Job Title
Address
Immediate Supervisor/Title
Telephone
Summarize the nature of work performed and job responsibilities
Reason for Leaving
Hourly Salary Start
Hourly Salary Final

(2)

Date Started
Date Ended
Employer
Job Title
Address
Immediate Supervisor / Title
Telephone
Summarize the nature of work performed and job responsibilities
Reason for Leaving
Hourly Salary Start
Hourly Salary Final

(3)

Date Started
Date Ended
Employer
Job Title
Address
Immediate Supervisor / Title
Telephone
Summarize the nature of work performed and job responsibilities
Reason for Leaving
Hourly salary Start
Hourly salary Final

SKILLS and QUALIFICATIONS

Summarize any training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying:

LICENSES or CERTIFICATIONS (Applicable only to medical personnel requiring state license)

License or Certification Number
State Issued

EDUCATIONAL BACKGROUND

High School
City
State
Years Completed
Year Graduated
College/School Name
City
State
Years Completed

Military

US Military Naval Service
Rank
National Guard Services
Type of Discharge

References

1.) Name
Telephone
Relationship
2.) Name
Telephone
Relationship
3.) Name
Telephone
Relationship
4.) Name
Telephone
Relationship
Resume Upload
 
I understand that if I am employed, an misrepresentation or material mission made by me on this application will be sufficient cause for cancellation of this application or immediate discharge from Irwin County Hospital(ICH) services whenever it is discovered. I give Irwin County Hospital(ICH) the right to contact and obtain information from all references, employees, educational institutions and to otherwise verify the accuracy of the information contained in this application. I hereby release from liability ICH and its representatives for seeking, gathering and using such information and all other persons, corporations or organizations for furnishing such information. This application is current for only six (6) months. At the conclusion of this period, if I have not heard from ICH and still wish to be considered for employment, it will be necessary to fill out a new application. If I am hired, I understand that I am free to resign at any time with or without prior notice and ICH reserves the same right to terminate my employment at any time with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no representative of the employer, other than an authorized officer, has the authority to make any assurances to the contrary. Further I understand that any such assurance must be in writing and signed by an authorized officer. I understand it is Irwin County Hospital policy not to refuse to hire a qualified individual based upon that person’s need for a reasonable accommodation as required by the ADA. I also understand that If hired, I will be required to provide proof of identity, legal work authorization, physical examination, drug screen, criminal background check and to serve the best of my ability and to abide by the policies established by the hospital authority and the administrator.