Welcome

To the Applicant: We appreciate your interest in our organization and assure you that we are sincerely interested in your qualifications. A clear understanding of your background and work history will aid us in placing you in the position that best meets your qualifications and may assist us in possible future upgrading.

This facility is an Equal Opportunity Employer. Employment, educational opportunities, and promotions in all job classifications are without regard to race, color, religion, national origin, sex, age, political affiliation, or sexual orientation.

Personal
Full Name (First, Middle, Last):	Position Applied For - #1:
Address (Street, City, State, ZIP):	Position Applied For - #2:
Telephone:	Rate of Pay Expected:
Social Security Number:	Date Available for Employment:
Type of employment interested in: Full Time Part Time Temporary
Specific days, hours if Part Time:

Professional
Current License (Type):	State:
Year:	Number:
Areas of experience in profession:

Educational Data
High School
Name of School:	Did You Graduate?:
Address:	Type of Degree:
Field of Study:
Business School, Vocational, or Correspondence School
Name of School:	Did You Graduate?:
Address:	Type of Degree:
Field of Study:
College or University
Name of School:	Did You Graduate?:
Address:	Type of Degree:
Field of Study:

General Information
Do you type?:	If so, words per minute:
Do you take dictation?:	If so, method:
Have you been convicted of a felony?:	If so, please explain:

Employment History
Present or Last Employer
Name:	Address:
Phone:	Supervisor:
Your Title:	Duties:
Last Salary:	Reason for Leaving:
Date Left (Month / Year)	Date Began (Month / Year)
May We Contact?:
Previous Employer
Name:	Address:
Phone:	Supervisor:
Your Title:	Duties:
Last Salary:	Reason for Leaving:
Date Left (Month / Year)	Date Began (Month / Year)
May We Contact?:
School or Personal References Which We May Contact (Please Do Not List Relatives)
Name:	Occupation:
Address:	Telephone:

Name:	Occupation:
Address:	Telephone:

Name:	Occupation:
Address:	Telephone:

Applicant's Statement
By submitting this application electronically: I hereby authorize investigation of all statements contained in this application. I affirm that all information contained in this application is true and complete and that any misrepresentations, falsification, or willful omission herein shall be sufficient reason for dismissal and/or refusal of employment. I agree that my employment is subject to the results of a physical examination. I authorize the Hendricks Community Hospital Association to investigate my previous academic background, experience, and qualifications, and hereby release to this facility information pertinent to my employment.

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