Name:

Phone:

Address:

City:

State:

Zip:

Position Applied For:

If you are applying for a specific position, how did you learn of the opening?
Newspaper
Internet
Pomerene Website
Pomerene Job Line
Other

Shift Preferred: First   Second   Third   Any

Special Training or Skills (languages, machine operation, etc) that would benefit you in the job for which you are applying:

Would you accept full-time work?      Yes    No

On what date would you be available for work? (MM-DD-YYYY)

Have you ever been employed here before?spacerYes    No

If Yes, Dates Employed: to

Do you have a legal right to be employed in the U.S.?     Yes (If yes, proof is required)   No

Are you of legal age to work?   Yes (If yes, proof is required)   No

Have you ever been convicted of a felony*?   Yes (If yes, please explain below)     No

*A record of criminal conviction does not necessarially bar your employment with Pomerene Hospital.

     Educational Background

Grammar School
(Name and Locaton):

Course of Study:

Did you graduate?

Yes    No

Degree or Diploma:

High School
(Name and Location):

Course of Study:

Did you graduate?

Yes   No

Degree or Diploma:

College
(Name and Location):

Course of Study:

Did you graduate?

Yes    No

Degree or Diploma:

Graduate School
(Name and Location):

Course of Study:

Did you graduate?

Yes    No

Degree or Diploma:

Vocational, or other training (Name and Location):

Course of Study:

Did you graduate?

Yes    No

Degree or Diploma:

Continuing Education:

Place a check in the box by the employer(s) you do not want us to contact. List most recent employer first.

Company Name:

Phone:

Contact Name:

Address:

Employed From:

Position:

Reason For Leaving:

Last Wage:

Company Name:

Phone:

Contact Name:

Address:

Employed From:

Position:

Reason For Leaving:

Last Wage:

Company Name:

Phone:

Contact Name:

Address:

Employed From:

Position:

Reason For Leaving:

Last Wage:

Company Name:

Phone:

Contact Name:

Address:

Employed From:

Position:

Reason For Leaving:

Last Wage:

I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected, and if I am employed, my employment may be terminated at any time.

In consideration of my employment, I agree to conform to the company's rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company's option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company. I understand that no company representative, other than it's president, and then only when in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing.

Type Your Name:

(this will act as your signature)