Homer Memorial Hospital

Apply On-line

Date of Application

Name

Email Address

Home Phone

Address

Who referred you to the site?

Were you referred by a current employee?:

Yes
No

Name of the employee who referred you

Legally authorized to work in the U.S.?:

Yes
No

Have you been convicted of a crime other than a minor traffic violation?

Please provide dates including offense charged and outcome

Are you currently under investigation or have you ever been sanctioned?:

Yes
No

Please provide date including reason for sanction and the outcome

JOB SOUGHT

Position Applying For

Department

Would you work

Can You Work

Date Available for Work

Starting Wage or Salary Desired

EDUCATION

Name of High School

Location

Years Completed

Diploma:

Yes
No

GED:

Yes
No

Name of College

Location

Years Completed

Major

Degree Earned

Name of Trade or Professional School

Location

Years Completed

Major

Diploma

Do you plan to attend school while working?:

Yes
No

Subjects of Study

U.S. MILITARY EXPERIENCE

Are you or have you been a member of the National Guard or Active Reserve?:

Yes
No

Do you have credentials (license, certification or registration)?:

Yes
No

Are your credentials current?:

Yes
No

Provide the registration number

Areas in which you are proficient

EMPLOYMENT

Have you ever worked for this hospital?:

Yes
No

When and under what name?

Are you presently employed?:

Yes
No

Name of employer

Can we contact your present employer for a reference?:

Yes
No

Employer`s Address and Phone Number

WORK HISTORY

Company Name

Company Phone

Dates worked?

Job Title

Address

Hours worked per week

Current or Final Salary

Last Supervisor

Reason for Leaving

Reason for inactivity between jobs

Company Name

Company Phone

Dates Worked?

Job Title

Address

Hours worked per week

Current or Final Salary

Last Supervisor

Reason for Leaving

Reason for Inactivity between jobs

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