PCH Application for Employment

Name
Present Address
Date:
Social Security #
Telephone Number
Have you ever worked at Princeton Community Hospital?	Yes No
If yes, date left
Are you either a U.S. citizen or an alien who has the legal right to work in the job for which you are applying?	Yes No Based on Immigration Reform and Control Act of 1986, all applicants must produce documents, which are specified by the federal government, establishing their identity and authorization for employment in the United States once an offer of employment has been made. These documents must be produced no later than seventy-two (72) hours after beginning employment. You will also be required to sign form 1-9 (Issued by the Federal government) verifying, under oath, your employment authorization.
Are you under 18?	Yes No
Position Applied for
Employment Availability	Full Time Work 7 - 3 Rotating Shifts Part Time Work 3 - 11 Weekends Temporary 11 - 7 Other
Date available to begin work
Have you served in the U.S. Armed Services?	Yes No
If yes, what branch?
Duties and special training in the military?
Have you ever been involuntarily discharged from a job?	Yes No
If yes, explain and give dates
	APPLICANTS WHO ARE LICENSED PROFESSIONAL PLEASE FILL OUT THE FOLLOWING:
Registration Number
State Issued
Date Expires
	For all applicants applying for employment in job areas that are direct patient care responsibilities, please fill out the following:
Have you ever been convicted of possession of any narcotic drug or controlled substance, including Marijuana?	Yes ** No ** Conviction of a criminal offense does not denote automatic disqualification for employment.
Date of conviction
City and State
Charge
Disposition of conviction
	PLEASE COMPLETE THE FOLLOWING EDUCATIONAL INFORMATION:
Type of School	Name and Location of School
High School
High School
Course of Study
Last year of high school completed	9 10 11 12
College
Course of Study
Last year of college completed	1 2 3 4
Other
Course of Study
Last year completed	1 2 3 4
Other
Course of Study
Last year completed	1 2 3 4
Skills:
	PLEASE COMPLETE ALL PRESENT AND PAST EMPLOYMENT, BEGINNING WITH YOUR MOST RECENT:
Name of Company/Institution
Address
Telephone
Name of Supervisor
Type of Business
Dates of Employment Position(s) Held
Salary
Reason for Leaving
Briefly summarize experience gained, including special training you received.
Name of Company/Institution
Address
Telephone
Name of Supervisor
Type of Business
Dates of Employment Position(s) Held
Salary
Reason for Leaving
Briefly summarize experience gained, including special training you received.
Name of Company/Institution
Address
Telephone
Name of Supervisor
Type of Business
Dates of Employment Position(s) Held
Salary
Reason for Leaving
Briefly summarize experience gained, including special training you received.
Please check employers we may contact:	1 2 3
	Give name(s) of persons we may contact to verify your qualifications for the position:
1. Name
Address
Telephone
Occupation
2. Name
Address
Telephone
Occupation

AFFIDAVIT I certify that the answers given by me to the foregoing questions and statements 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 application. I authorize the employers, companies, schools or any persons named above to give any information regarding my employment, together with any information 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 damage, both legal and otherwise, for issuing this information. I also understand employment will be conditioned on results of a 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 myself or my employer. Signed (your name) Date WE ARE AN EQUAL OPPORTUNITY EMPLOYER - A COPY OF THIS APPLICATION IS AVAILABLE TO YOU ON REQUEST. APPLICANT: To facilitate checking your past employment and/or school references, please sign the following statement that may be sent by Princeton Community Hospital to your previous employers/schools to authorize reference information. Thank you. I authorize the employers, companies, schools or persons named above to give any information regarding my employment, together with any information 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 damage, both legal and otherwise, for issuing this information. Signed (your name) Date APPLICANT: Please read and acknowledge understanding by signing: This facility is an equal opportunity employer. We do not discriminate on the basis of race, religion, sex, color, national origin, age, disability or pregnancy. However, because of the large number of people that are seeking employment, we cannot possibly interview everyone that completes an application. We will, however, consider your qualifications in light of the positions we have available, and based on this information, and the fact that we are seeking the applicant most tailored to the needs of the job, we will then schedule interviews. PLEASE NOTE: Your application will remain active for ninety (90) days from the date of this application for the position listed. You must reapply at the end of that time period in order to keep your application current. A separate application must be completed for each position for which you are interested. Signed (your name) Date Fax the completed form to 304-487-7795, or mail to: Princeton Community Hospital, P.O. Box 1369 Princeton, WV 24740 Attention: Human Resources Dept. HOME