Employment Application Please enable JavaScript in your browser to complete this form. - Step 1 of 5CMH Online ApplicationChambers Memorial Hospital consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status. Chambers Memorial Hospital is an Equal Employment Opportunity Employer. We comply with all applicable state and federal civil rights and equal employment laws and regulations. NOTICE TO APPLICANTS AND EMPLOYEES: Screening test for alcohol and illegal drug use may be required before hiring and during your employment here.PERSONAL INFORMATIONName *FirstMiddleLastPhone *Email *Present Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePermanent AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePosition Applied For *Salary DesiredHow were you referred to this facility?Date available for work *Relatives or friends employed in this facility? *YESNOIf yes, what department?Have you ever been employed by this facility? *YESNOIf yes, when and by what department?Are you 18 years old or younger? *YESNOWould you consider working Weekends & Holidays? *YESNOWould you consider working Rotating Shifts? *YESNOWould you consider working On Call? *YESNOWould you consider working Any Shift? *YESNOShift Preference *DAYSEVENINGSNIGHTSLong range occupational goals:Are you a U.S. Citizen or an alien legally authorized to work in the United States? *YESNOHave you been convicted of a felony? *YESNOIf yes, explain.After reviewing the functions of the job you are applying for, do you have any physical/mental condition that would substantially limit your ability to perform that job? *YESNOIf yes, explain.NextEDUCATION / SKILLSName of High SchoolAddress of High SchoolAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDid you graduate?YESNOName of College #1Address of College #1Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCourse of StudyCheck last year completed1234Did you graduate?YESNOList Diploma or DegreeName of College #2Address of College #2Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCourse of StudyCheck last year completed1234Did you graduate?YESNOList Diploma or DegreeOther Business College, Other Special Courses (include Special Military Training, Post Graduate and Nursing)Area of Specialization or Major Interest:List Business or Industrial Equipment Operated:If Licensed, Registered or CertifiedType/State Issued/Date/No.Are you currently:RegisteredLicensedCertifiedAre you eligible for:RegistrationLicensureCertificationType/State Issued/Date/No.Are you currently:RegisteredLicensedCertifiedAre you eligible for:RegistrationLicensureCertificationType/State Issued/Date/No.Are you currently:RegisteredLicensedCertifiedAre you eligible for:RegistrationLicensureCertificationLanguage SkillsDo not complete unless requested.Language #1I SPEAK the above languageFairGoodFluentI READ the above languageFairGoodFluentI READ/WRITE the above languageFairGoodFluentLanguage #2I SPEAK the above languageFairGoodFluentI READ the above languageFairGoodFluentI READ/WRITE the above languageFairGoodFluentPreviousNextPrevious Experience #1List name, address and phone number of previous employers with most recent employer first.Job TitleEmployer NameAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmployers Phone No.Employed From / ToImmediate SupervisorLast Salary (hourly, monthly or yearly)DutiesReason for LeavingPrevious Experience #2List name, address and phone number of previous employers with most recent employer first.Job TitleEmployer NameAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmployers Phone No.Employed From / ToImmediate SupervisorLast Salary (hourly, monthly or yearly)DutiesReason for LeavingPrevious Experience #3List name, address and phone number of previous employers with most recent employer first.Job TitleEmployer NameAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmployers Phone No.Employed From / ToImmediate SupervisorLast Salary (hourly, monthly or yearly)DutiesReason for LeavingPreviousNextREFERENCESList at least 3 references who are not relatives or employees of Chamber Memorial HospitalName & Relationship - Reference #1Title - Reference #1Company Name - Reference #1Address - Reference #1Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone - Reference #1Name & Relationship - Reference #2Title - Reference #2Company Name - Reference #2Address - Reference #2Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone - Reference #2Name & Relationship - Reference #3Title - Reference #3Company Name - Reference #3Address - Reference #3Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone - Reference #3PreviousNextCAREFULLY READ THIS SECTION PRIOR TO CHECKING THE BOX BELOW:I consent to any medical examination required by the facility at any time to determine my ability to perform the duties of my job or other jobs with the facility and I understand that my employment may be conditioned upon satisfactorily passing a physical examination. I understand that I may be required to satisfactorily complete an alcohol/drug screening as a condition of employment. I understand that my employment can be terminated at any time and for any reason, at the option of either the facility or myself. I understand that no one has any authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing, except for a written employment agreement signed by an administrative representative of this facility. I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete. I understand that nay false or misleading representations or omissions may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date. I hereby authorize persons, schools, my current employer (if applicable) and previous employers and organizations named in this application (and accompanying resume, if any) to provide this facility and all affiliates with any relevant information regarding an employment decision, and I release all such persons from any liability regarding the provision or use of such information.I AGREE TO THE ABOVE *YESNOUpload Your Resume or accompanying document (PDF format required) Click or drag a file to this area to upload. PreviousSubmit Have a question? Contact us today! Contact CMH