Personal Information Last Name* First Name* Phone* Email Street Address* City* State* Zip* Social Security Number* Are you authorized to work in the U.S.?* Yes No Have you ever been convicted of a felony?* Yes No If yes, please explain.* Are you a veteran?* Yes No Branch, MOS, and Type of discharge Desired Postion Title of Position Desired Salary or Wage* Date You Can Start* What type of work do you want?* Full Time Part Time Specify the days and hours you would like to work.* Did someone refer you to this position? If so who can we thank? How did you hear about this position?* Herington Hospital Website Employment Agency Radio Newspaper Other Which specific one(s) did you hear about the position from? Educational Background High School Name of High School Location of High School Subjects (If applicable) Dates Attended Did you graduate? Yes No Higher Education Name of College, University, or Tech School Location Subjects (If applicable) Dates Attended Did you graduate? Yes No Name of College, University, or Tech School #2 (if applicable) Location Subjects (If applicable) Dates Attended Did you graduate? Yes No Employment History Are you currently employed?* Yes No May we contact your present employer?* Yes No Have you ever worked for Herington Hospital?* Yes No When did you work for Herington Hospital?* Why did you leave Herington Hospital?* Previous Employer 1* Company Name Address Ending Salary Position Held Reason for Leaving* Dates Employed* From To Previous Employer 2 Company Name Address Ending Salary Position Held Reason for Leaving Dates Employed From To Previous Employer 3 Company Name Address Ending Salary Position Held Reason for Leaving Dates Employed From To List any volunteer or community service positions (work) which you feel are related to the position for which you are applying. Briefly state any special skills or qualifications you have which you feel are related to the position for which you are applying. Personal References Give below the names of three persona not related to you, whom you have known at least 1 year. Reference 1* Reference Name Occupation Address Phone Number Reference 2* Reference Name Occupation Address Phone Number Reference 3* Reference Name Occupation Address Phone Number Other files Would you like to upload a cover letter? Accepted file types: doc, docx, pdf, Max. file size: 200 MB. Upload other files that you think will be beneficial. Drop files here or Select files Accepted file types: docx, doc, pdf, Max. file size: 200 MB, Max. files: 3. Certification & Authorization This institution does not discriminate in hiring or any other decision on the basis of race, color, religion, sex, citizenship, national origin, sexual orientation, gender identity, ancestry, Vietnam era veteran status, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination. I certify that my answers are true and complete to the best of my knowledge. I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I consent to take the physical examination and drug screen and such future physical examinations as may be required by this institution at such times and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physician examination which relates to the essential duties I would be required to perform. I understand that my employment is at will and that either party is free to terminate the employment relationship at any time without cause. I understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form Signature* Date* Month Day Year CAPTCHA Comments This field is for validation purposes and should be left unchanged.
