Employment Application

CMH Online Application

Chambers 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 INFORMATION

Name *

First

Middle

Last

Phone *

Email *

Present Address *

Address Line 1

Address Line 2

City

State

Zip Code

Permanent Address

Address Line 1

Address Line 2

City

State

Zip Code

Position Applied For *

Salary Desired

How were you referred to this facility?

Date available for work *

Relatives or friends employed in this facility? *

YES
NO

If yes, what department?

Have you ever been employed by this facility? *

YES
NO

If yes, when and by what department?

Are you 18 years old or younger? *

YES
NO

Would you consider working Weekends & Holidays? *

YES
NO

Would you consider working Rotating Shifts? *

YES
NO

Would you consider working On Call? *

YES
NO

Would you consider working Any Shift? *

YES
NO

Shift Preference *

DAYS
EVENINGS
NIGHTS

Long range occupational goals:

Are you a U.S. Citizen or an alien legally authorized to work in the United States? *

YES
NO

Have you been convicted of a felony? *

YES
NO

If 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? *

YES
NO

If yes, explain.

EDUCATION / SKILLS

Name of High School

Address of High School

Address Line 1

Address Line 2

City

State

Zip Code

Did you graduate?

YES
NO

Name of College #1

Address of College #1

Address Line 1

Address Line 2

City

State

Zip Code

Course of Study

Check last year completed

1
2
3
4

Did you graduate?

YES
NO

List Diploma or Degree

Name of College #2

Address of College #2

Address Line 1

Address Line 2

City

State

Zip Code

Course of Study

Check last year completed

1
2
3
4

Did you graduate?

YES
NO

List Diploma or Degree

Other 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 Certified

Type/State Issued/Date/No.

Are you currently:

Registered
Licensed
Certified

Are you eligible for:

Registration
Licensure
Certification

Type/State Issued/Date/No.

Are you currently:

Registered
Licensed
Certified

Are you eligible for:

Registration
Licensure
Certification

Type/State Issued/Date/No.

Are you currently:

Registered
Licensed
Certified

Are you eligible for:

Registration
Licensure
Certification

Language Skills

Do not complete unless requested.

Language #1

I SPEAK the above language

Fair
Good
Fluent

I READ the above language

Fair
Good
Fluent

I READ/WRITE the above language

Fair
Good
Fluent

Language #2

I SPEAK the above language

Fair
Good
Fluent

I READ the above language

Fair
Good
Fluent

I READ/WRITE the above language

Fair
Good
Fluent

Previous Experience #1

List name, address and phone number of previous employers with most recent employer first.

Job Title

Employer Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Employers Phone No.

Employed From / To

Immediate Supervisor

Last Salary (hourly, monthly or yearly)

Duties

Reason for Leaving

Previous Experience #2

List name, address and phone number of previous employers with most recent employer first.

Job Title

Employer Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Employers Phone No.

Employed From / To

Immediate Supervisor

Last Salary (hourly, monthly or yearly)

Duties

Reason for Leaving

Previous Experience #3

List name, address and phone number of previous employers with most recent employer first.

Job Title

Employer Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Employers Phone No.

Employed From / To

Immediate Supervisor

Last Salary (hourly, monthly or yearly)

Duties

Reason for Leaving

REFERENCES

List at least 3 references who are not relatives or employees of Chamber Memorial Hospital

Name & Relationship - Reference #1

Title - Reference #1

Company Name - Reference #1

Address - Reference #1

Address Line 1

Address Line 2

City

State

Zip Code

Phone - Reference #1

Name & Relationship - Reference #2

Title - Reference #2

Company Name - Reference #2

Address - Reference #2

Address Line 1

Address Line 2

City

State

Zip Code

Phone - Reference #2

Name & Relationship - Reference #3

Title - Reference #3

Company Name - Reference #3

Address - Reference #3

Address Line 1

Address Line 2

City

State

Zip Code

Phone - Reference #3

CAREFULLY 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 *

YES
NO

Upload Your Resume or accompanying document (PDF format required)

Click or drag a file to this area to upload.

CMH Online Application

PERSONAL INFORMATION

EDUCATION / SKILLS

If Licensed, Registered or Certified

Language Skills

Previous Experience #1

Previous Experience #2

Previous Experience #3

REFERENCES

CAREFULLY READ THIS SECTION PRIOR TO CHECKING THE BOX BELOW:

Have a question? Contact us today!