ONLINE APPLICATION

Date:
Name (first, middle, last):
Home Phone:
Salary or Wages Desired:
   Hr.   Wk.   Mo.   Yr.  
Position(s) applied for:
Experience, Certifications, Special Qualifications or Skills:
May we contact you by E-mail:
Yes   No   
E-mail Address:
PERSONAL
Address:
City:
State:
Zip:
Work Phone:
How did you find out about us?
If Employee/Other:
Are you over 18 years of age?
If NO, a work permit will be required.
Yes         No
Are you legally eligible for permanent employment in the United States? (If hired, verification will be required by law.)
Yes         No
Full time:

Part time:

If part time, list days/hours available (including AM and PM):

Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
Date you are available to start work:
Have you worked for us before?    Yes No
If so, when?
EDUCATION
Name and Location of School
Course of Study
Years Completed
Did you graduate?
Elementary
Yes No
High School
Yes No
College
Major:
Degree:
Yes No
Other
Yes No
Are you employed at the present time?
Yes      No
If hired, will you work overtime if required?
Yes      No
Have you ever been bonded in prior employment?
Yes      No

If YES, list names of employers:
Have you ever been convicted of a crime (excluding misdemeanors and traffic offenses)?
Yes      No

If YES, list convictions:
(A conviction does not necessarily disqualify an applicant for the position being applied for.)

PRIOR EMPLOYMENT
(Start with most recent employer)

Employer 1:
Address:
City: State: Zip:
Phone:
Employment Dates: From: To:
Position:
Duties:
Reason for leaving:
Supervisor's Name:
May we contact?
Yes      No
Starting Salary/Wages:
Final Salary/Wages:
Employer 2:
Address:
City: State: Zip:
Phone:
Employment Dates: From: To:
Position:
Duties:
Reason for leaving:
Supervisor's Name:
May we contact?
Yes      No
Starting Salary/Wages:
Final Salary/Wages:
Employer 3:
Address:
City: State: Zip:
Phone:
Employment Dates: From: To:
Position:
Duties:
Reason for leaving:
Supervisor's Name:
May we contact?
Yes      No
Starting Salary/Wages:
Final Salary/Wages:

MILITARY SERVICE

Branch of Service
From
To
Rank and Duties Date Discharged

PERSONAL REFERENCES

Name
Address
Years Known
Telephone

READ CAREFULLY

The above information is true and complete to the best of my knowledge. Should I be employed by Osceola Medical Center, any misrepresentation or false statement contained herein may be considered cause for possible dismissal. Osceola Medical Center has my permission to obtain all necessary information from the references I have listed, or any other sources, concerning my prior employment, personal history or credit standing and I release all parties from any possible damages resulting from disclosing such information with or without prior written notice to me. I reserve the right to know the names and addresses of any investigative agencies used in order that I may learn the information contained in any reports furnished to Osceola Medical Center.


I understand this application does not constitute an employment contract of any kind. Should I be employed by Osceola Medical Center, I may resign such employment at any time at my discretion with or without prior notice and Osceola Medical Center may terminate my employment at any time at their discretion, with or without cause and with or without prior notice.


IMPORTANT: By entering the date and applicant information below and by clicking on the Submit button, you agree that you understand fully and will abide by the terms of the above notice.

Date:
Name of Applicant: