Job Application - Oceana Medical Care Facility

POSITION APPLIED FOR *

Referral Source *

Were you referred to us by an employee? *

PLEASE LIST THE NAME OF EMPLOYEE *

Your Name *

First

Middle

Last

Your Address: (Street) *

CIty *

State *

Zip Code *

Telephone No. *

Email Address *

Specify any days or times you are not available for work: *

Can you work overtime, including weekends? *

Salary Expectation *

Per *

What shift(s) are you willing to work? *

What date are you available to start? *

Employment Status Desired *

Full Time
Part Time

Have you ever been employed by the Oceana County Medical Care Facility? *

Date Started *

Date Left *

In What Department *

In What Position *

Reason for leaving

Are you eligible to work in the U.S.? *

Proof of eligibility to work in Us. Must be provided if selected for hire.

Do you have a legal right to remain permanently in the United States? *

If employed, can you submit verification of your legal right to remain in the U.S.? *

Do you have a reliable form of transportation available to you to go to and from work? *

MILITARY SERVICE

Service

Branch

Date of Service

From

Reserve Status

EMPLOYMENT HISTORY-

List your last four employers, or all employers for the last ten years, whichever is greater. Attach additional signed sheets if necessary. Also list and explain any period(s) of unemployment. Please answer all inquiries. “See Resume” is not acceptable.

Employer’s Name *

Dates Worked (month and year)

From *

To *

Address (Street, City, State and Zip Code) *

Telephone *

Supervisor (Name & Title) *

Supervisor (Email) *

Your Title *

Your Salary *

Duties & Responsibilities *

Reason for leaving *

May we call this reference? *

Add employer (2)

Employer’s Name *

Dates Worked (month and year)

From *

To *

Address (Street, City, State and Zip Code) *

Telephone *

Supervisor (Name & Title) *

Supervisor (Email) *

Your Title *

Your Salary *

Duties & Responsibilities *

Reason for leaving *

May we call this reference? *

Add Employer (3)

Employer’s Name *

Dates Worked (month and year)

From *

To *

Address (Street, City, State and Zip Code) *

Telephone *

Supervisor (Name & Title) *

Supervisor (Email) *

Your Title *

Your Salary *

Duties & Responsibilities *

Reason for leaving *

May we call this reference? *

Add Employer (4)

Employer’s Name *

Dates Worked (month and year)

From *

To *

Address (Street, City, State and Zip Code) *

Telephone *

Supervisor (Name & Title) *

Supervisor (Email) *

Your Title *

Your Salary *

Duties & Responsibilities *

Reason for leaving *

May we call this reference? *

Have you ever been discharged by an employer or resigned in lieu of discharge? *

If you answered yes to either of the two previous questions, explain all such incidents, giving facts, dates, describing any action you took and any resolution, on an attached signed sheet. How much time have you missed from work in the past twelve months? *

Do you have a valid driver’s license? *

EDUCATION

High School *

Location *

Degrees *

Business/Trade/Vocational School *

Location *

Degrees *

College/University *

Location *

Degrees *

PROFESSIONAL LICENSES, REGISTRATIONS, AND/OR CERTIFICATIONS

List all states in which you are or have been licensed or certified and any national certifications. *

Attach additional pages if necessary.

Click or drag files to this area to upload. You can upload up to 10 files.

Have you ever had any professional license or certification placed under investigation, disciplined, suspended, revoked or put on probation? *

You answered yes to either above questions, explain in detail on an attached signed statement. *

MISCELLANEOUS

Have you ever been arrested or convicted of a felony? *

Conviction of a crime will not necessarily disqualify an application from employment.

Have you ever been arrested or convicted of a misdemeanor? *

Conviction of a crime will not necessarily disqualify an application from employment.

You answered yes to either of the two proceeding questions, explain by giving the date, nature of the offense and circumstances in an attached, signed statement. Conviction of a crime will not necessarily disqualify an applicant from employment. *

Are you 18 years of age or older? *

If no, you may be required to provide authorization to work.

Are you able to perform the essential functions of the job for which you have applied, with or without accommodation? *

Resume Upload *

Click or drag a file to this area to upload.

Please attach your resume.

CERTIFICATION

I have read and fully under the questions on this application for employment. I have completely, truthfully, and accurately answered every question to the best of my knowledge. I understand that any misrepresentation of the information I have supplied or failed to supply can result in rejection of this application or, if I have been hired, could affect said employment.

Signature of Applicant *

Clear Signature

Date *