Application For Employment

Federal and state laws prohibit discrimination in employment because of race
color, creed, age, sex, marital status, national origin, physical or mental impairment,
or medical condition. Fill out the application below. When complete click the SUBMIT
button at the bottom of the form to have your application submitted automatically.
Use your browsers BACK button to return to the Employment page.

Please complete ALL fields of the application.
Navigate through the application by using the tab key.
(Do not press the enter key because it submits your application incomplete)
Click the submit button when you have completed the entire application.

Applications are kept active for 6 months. After 6 months, applications
are archived and you will need to fill out a new application.

Please Complete All Fields                                                                                                               

Application Date:

Referred By:

Name         
Email Address

Full Address (Street, City, State, Zip)

Telephone:
Home:
Business:
Other

I am available: Full Time  Part Time
If Part Time specify hours available:
Shift desired: Day     Evening     Night
Date Available for work:
Position(s) applying for:
(Nursing applicants list specialty)

 Social Security Number:

Have you ever been employed by us?
Yes No

If yes, when?

Are you a U.S. Citizen? Yes  No
If no, visa type
Date Granted: 


Education

Highest grade completed: 1-12                                 College or Tech: 1-7
Type of School School Name & Address Major Minor Degree Received Dates Attended
High School

College

Graduate School

Fields of work for which you are licensed, or certified:
Certificate/License No.   Renewal No.
Year of License

Special skills you wish considered:

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General Information

Have you ever been convicted of or forfeited bond in connection with a criminal offense?
Yes    No
If yes, explain:

List the names of departments of HCHS in which relatives are employed:

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References: Educational, Professional, Work related (No Relatives)

Name Address Telephone Number
W.
H.
H.
W.
H.
W.

 

Employment History
Please give accurate, complete full-time and part-time employment record. Start with present or most recent employer.

Company Name
Address 
Name and Title of Superior
State Job Title and Describe your work  
Full time      Part time
 Telephone
Employed (State month and Year)
From:
To:   
Hourly Pay
Start:
Last: 
Reason for Leaving

Company Name
Address 
Name and Title of Superior
State Job Title and Describe your work  
Full time      Part time
 Telephone
Employed (State month and Year)
From:
To:   
Hourly Pay
Start:
Last: 
Reason for Leaving

Company Name
Address 
Name and Title of Superior
State Job Title and Describe your work  
Full time      Part time
 Telephone
Employed (State month and Year)
From:
To:   
Hourly Pay
Start:
Last: 
Reason for Leaving

Military Service
Have you ever served in the U.S. Military?
Yes     No

Please list any job-related skills or experience:

Statement Of Health
Can you perform the essential functions of the position for which you are applying safely?
Yes      No

Explain:

 

Are you willing to take a physical examination, drug test and criminal record check at our expense upon a conditional offer of employment?

Yes      No

 Have you ever been sanctioned by or excluded from participation in Medicare, Medicaid or any
 government health program?      Yes      No

Are you currently under investigation for sanctioned issues?     Yes      No

May we contact your present employer?     Yes      No

Affidavit. I certify that the answers given by me in the foregoing questions are true and correct without consequential omissions of any kind whatsoever, I agree that my employer shall not be liable in any respect if my employment is terminated because of falsity of statements, answers or omissions made by me in this question. I authorize employers, companies, schools or persons named above to give information regarding my employment, together with any information that they may have regarding me whether or not it is in their records. I hereby release said employers, companies, schools or persons from all liability for any damages, both legal and otherwise, for issuing this information. I also understand a conditional offer of employment may be based on the results of a later medical examination. In addition. if accepted for employment, I hereby agree to abide by the rules and policies of my employer. Further, I understand that any employment is not for a stated period of time and may be terminated with or without cause, at any time, at the option of either my employer or myself. In addition, should my employer be or become subject to the conditions of the Drug Free Workplace Act of 1988, I agree to abide by such established policies as related thereto.
                                  _ ________________________________________________________________________
We are a equal opportunity employer-a copy of this application is available to you upon request.

Hugh Chatham Memorial Hospital   PO Box 560, Elkin NC 28621  (336)527-7660  Fax (336)527-7663   www.hughchatham.org