TO ALL APPLICANTS:

Applications are to be

completed and returned to the HUMAN RESOURCE OFFICE ONLY

This will ensure proper

handling procedures as well

as proper routing.

Thank you!

MEMORIAL HOSPITALAPPLICATION FOR EMPLOYMENT

1401 West Locust Street / P O Box 272, Stilwell, OK 74960

Ph: 918-696-3101 Fax: 918-696-3388

PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE

Name ______

Last First Middle Maiden

List ALL other names you’ve ever used or been know by______

______

Present Address ______

Number Street City State Zip

How long at above address______Social Security No. ______-_____-______

Telephone (______)______Please Circle: Home Cell Other ______

If under 18, list age ______Emergency Contact Name & Phone ______

Next of Kin Name & Phone ______

How were you referred to this facility?______

Position applied for: (Circle all that apply, if you do not know what the initials mean do not circle)

RN, LPN, CNA, MT, MLT, CRT, RRT, ARRT, CCS. CCA, PTA, CLERICAL, COOK, HOUSEKEEPER, MAINTENANCE,

SECURITY, INTERNET TECH, OTHER NOT LISTED______

Days and Hours Available or Willing to work (bespecific)______

______

Salary Desired ______Employment Desired (Circle) Full-time Only; Part-time Only; Full or Part-time

What date would you be available for work? ______

Have you ever worked for this hospital? ______

If yes, When and what Department? ______

Are you related to anyone that works here? _____ If yes, who? ______

______

Are you a U.S. Citizen or an Alien legally authorized to work in the United States ___ Yes ___ No

HAVE YOU EVERY BEEN CONVICTED OF A CRIME UNDER ANY NAME? ___ Yes ___ No (A felony conviction does not automatically disqualify you from employment) If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation. ______

______

Do you have a Driver’s License? ______What is your means of transportation? ______

Complete the section below only if you are applying for a job which requires on the job driving or otherwise instructed by Memorial Hosp to do so

Driver’s license number ______State of Issue ______Expiration ______

Have you had any accidents during the past three years? ______How many? ______

Have you had any moving violations during the past three years? ______How many? ______

OFFICE ONLY COMPLETE THIS SECTION:

Typing ___No ___Yes, WPM ______10-kay ___No ___Yes Word Processing ___No ___Yes, WPM_____

Personal Computer ___No ___Yes, ___PC or ___Mac Other______

MILITARY

Have you ever been in the Armed Forces? ______

Are you now a member of the National Guard? ______

Specialty ______Date Entered______Discharge Date______

Please list two references other than relatives or previous employers

Name ______Name______

Position______Position ______

Company______Company______

Address______Address______

______

Telephone (_____)______Telephone (_____)______

EDUCATION

High School Name & Address______

Did you Graduate? ___Yes ___ No Number of years completed______

College Name & Address______

Degree Received? ______, if yes, what type of degree______

Other Training or degrees______

______

WORK EXPERIENCE

Please list your work experience for the past five years beginning with your most recent job held. If you were self employed, give firm name. Attach additional sheets if necessary.

Name of employer______Supervisor______

Address______Start Date______

Your last job title______End Date______

Phone Number______Pay or Salary______

Reason for Leaving (be specific)______

Name of employer______Supervisor______

Address______Start Date______

Your last job title______End Date______

Phone Number______Pay or Salary______

Reason for Leaving (be specific)______

Name of employer______Supervisor______

Address______Start Date______

Your last job title______End Date______

Phone Number______Pay or Salary______

Reason for Leaving (be specific)______

May we contact your present or former employer(s)?______, If no, state which ones & reason______

______

Please explain any gaps in employment dates______

Make any comments you feel we should know when we contact your previous employers______

______

______

BACKGROUND SUMMARY

An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying______

______

______

PLEASE READ THE FOLLOWING CERTIFICATION CAFEFULLY BEFORE SIGNING JOB APPLICANT’S CERTIFICATION

I certify that the information given by me in this application is true in all respects, and I agree that if the information given is found to be false in any way, it shall be considered sufficient reason for denial of employment or discharge. I authorize the use of any information in this application to verify my statements except as indicated above. I authorize the past employers, all references, and any other persons to answer all questions asked concerning my ability, character, reputation and previous education or employment record. I release all such persons from any liability or damages on account of having furnished such information. I consent to such investigations as Memorial Hospital may make regarding driving records, law enforcement records, credit reports, and my general background. I understand that nothing contained in this employment application or in granting of an interview or of a position of employment is intended to be a contract between Memorial Hospital and myself for either employment or for the providing of any benefits. No promises regarding employment have been made to me and I understand that no promise or guarantee of employment for any specific length of time or under any specified circumstances shall be binding upon Memorial Hospital unless made in writing by or with the express written consent and authorization of the CEO or his designee. If an employment relationship is established, I understand that I have the right to terminate employment at any time and for any reason and that Memorial Hospital retains the same right. I understand that, depending of the position applied for, prior to being offered employment with Memorial Hospital I may be requested to take an examination pertaining to skills or equipment operation. In the event I have a disability which will affect my ability to take the test, I will so inform Memorial Hospital prior to the administration of the test so that a reasonable accommodation can be made. Memorial Hospital reserves the right to require medical documentation concerning the need for the accommodation. I understand that if I am initially offered a position of employment, Memorial Hospital may require me to pass a medical exam prior to the commencement of work and as a condition of employment. I understand that if employed, the policies and rules which are issued by Memorial Hospital are not conditions of employment and that Memorial Hospital may revise policies and procedures in whole or in part unilaterally at any time. IMPORTANT: If you do not understand or if you disagree with any portion of the above certification, do not sign before discussing with Memorial Hospital Human Resource Department when submitting your application.

Signature of applicant______Date______

APPLICANT PLEASE DO NOT WRITE IN THE SPACE BELOW!!!!!!!!!!

FOR DEPARTMENT DIRECTOR USE ONLY

DATE TO START TO WORK______DEPARTMENT______

RATE OF PAY______SHIFT______

JOB TITLE______YEARS OF EXPENIENCE______

STATUS _____FULL-TIME _____PART-TIME _____PRN _____TEMPORARY

REMARKS______

______

______

FIRST 90 DAYS OF EMPLOYMENT IS ON A PROBATIONARY TYPE BASIS

Signature of Employee______

Signature of Supervisor______

Signature of Administrator or Designee______