Employment Application Page | Olney Hamilton Hospital

In considering your application for employment, the facility may conduct a detailed and thorough investigation, which may include but is not limited to criminal record check, interviews or inquiries of prior employers, co-workers, acquaintances, relatives or friends.

PERSONAL INFORMATION

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Any previous names?

No
Yes

Please identify all other names including maiden name (one full name per line please).

Social Security Number*

Primary Phone Number*

Primary Phone Type*

Alternate Phone Number

Alternate Phone Type

Best Time to Contact You

Daytime (8am-5pm)
Evening (5pm-9pm)

You Are Applying For:

Full-Time Position
Part-Time Position
PRN

You Are Able To Work:

Daytime
Evening
Any Shift

Shift Preferences:

Days
Evenings

Are you a United States citizen or an alien legally authorized to work in the United States?*

Yes
No

Position you are applying for:*

How were you referred to our hospital?

Do you have relatives or friends employed here?

No
Yes

Relative/Friend Name

Department

Relationship

Have you been employed here in the past?*

No
Yes

Start Date*

Stop Date*

Have you ever been convicted of or plead guilty to a crime (excluding misdemeanor traffic violations)?*

No
Yes

Please Explain*

Have you ever been involved in the substantiated abuse of neglect of children or adults under the laws of this or any other state of the United States?*

No
Yes

Please Explain*

If your answer is “yes” to either of the above, you will not automatically be disqualified from employment considerations, except as required by state or federal law.

EDUCATION

High School Name

High School Address

City State / Province / Region Country

High School Course of Study

High School Years Completed

High School: Did you graduate?

Yes
No

College Name

College Address

City State / Province / Region Country

College Course of Study

College Years Completed

College: Did you graduate?

Yes
No

List College Diploma/Degree

College Name

College Address

City State / Province / Region Country

College Course of Study

College Years Completed

College: Did you graduate?

Yes
No

List College Diploma/Degree

Other business college or special courses (including special military training, post graduate and nursing):

Other areas of specialization or major interest:

Word Processing (approximate Words Per Minute)

List healthcare, business or industrial equipment operated:

PROFESSIONAL LICENSES

Type

State

Date

License Number

License Status

Currently licensed
Currently registered
Eligible for license
Eligible for registration

License or registration ever suspended, revoked or on probation?

No
Yes

Please Explain:

Additional License: Type

State

Date

License Number

License Status

Currently licensed
Currently registered
Eligible for license
Eligible for registration

License or registration every suspended, revoked or on probation?

No
Yes

Please Explain:

PROFESSIONAL CERTIFICATES

Type

State

Date

Certificate Number

Certificate Status

Currently Certified
Eligible for Certification

Additional Certificate: Type

Date

State

Certificate Number

Certificate Status

Currently Certified
Eligible for Certification

ARMED SERVICES/VOLUNTEER INFORMATION

Do you serve in the U.S. Armed Services?

No
Yes

What branch?

Service Started

Service Ended

Have you volunteered your time or services?

No
Yes

Where?

Briefly describe duties and skills acquired through military or volunteer service (include dates):

PREVIOUS EXPERIENCE – Provide information regarding previous employment beginning with most recent employer.

Start Date

Stop Date

Job Title

Supervisor's Name:

Salary

Salary Type

Employer Name

Employer Phone

Employer Address

Street Address Address Line 2 City State ZIP Code

Duties:

Reason for leaving:

Start Date

Stop Date

Job Title

Supervisor's Name:

Salary

Salary Type

Employer Name

Employer Phone

Employer Address

Street Address Address Line 2 City State ZIP Code

Duties:

Reason for leaving:

Start Date

Stop Date

Job Title

Supervisor's Name:

Salary

Salary Type

Employer Name

Employer Phone

Employer Address

Street Address Address Line 2 City State ZIP Code

Duties:

Reason for leaving:

Start Date

Stop Date

Job Title

Supervisor's Name:

Salary

Salary Type

Employer Name

Employer Address

Street Address Address Line 2 City State ZIP Code

Employer Phone

Duties:

Reason for leaving:

Pleaes identify and explain any gaps in employment longer than three (3) months:

May we contact any/all of your previous employers?

Yes
No

PERSONAL REFERENCES

Reference #1: Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Occupation

Years Known

Reference #2: Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Occupation

Years Known

Reference #3: Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Occupation

Years Known

Reference #4: Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Occupation

Years Known

Reference #5: Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Occupation

Years Known

Consent*

I agree to the terms of this employment application.

READ BEFORE SUBMITTING: By submitting this employment application I certify that all of the information provided in this employment application is true and complete to the best of my knowledge. I understand that any false or incomplete information may disqualify me from further consideration for employment and may result in my immediate discharge if discovered at a later date. I authorize the investigation of any or all statements contained in this application and also authorize any person, school, current employer, past employers, and other organizations to provide information concerning my previous employment and other relevant information that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I understand that Olney Hamilton Hospital may conduct a criminal background check on me. I have given permission for such a check to be done, and I also give permission to Olney Hamilton Hospital to review and information about me on the Texas Adult Abuse Registry and the Texas Child Protective Services Registry.

Signature*

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