APPLICANT INSTRUCTIONS
Thank you for your interest in working at our hospital. We appreciate your application
and look forward to the possibility of your joining our team. This sheet is for your
information. Please tear it off and keep it for your reference.
Please complete the attached application and authorization for release of information
forms. Please print all information so it may be easily read. Be certain all forms are completely filled out and signed. Use the abbreviation of “N/A” if a particular provision
or section in the form is not applicable to you. Incomplete applications will not be
considered.
Your application will remain in our active files for a period of one year. Should an
appropriate opening occur, your application will be reviewed along with others. It is
not necessary for you to contact this office regarding any job opening after you have completed your application. If you are among the most qualified applicants for a
position an interview will be arranged. Please notify us in writing if your address
or telephone number changes.
Employment decisions are made solely on the basis of qualifications to perform the work
for which you are applying. Qualifications include education, training and work
experience. Credentials and experience will be verified through schools, former
employers and licensing/certification agencies, if applicable. As an Equal Opportunity
employer, decisions to hire and promote are made without regard to race, color, creed, national origin, sex, physical or mental handicap (unrelated to ability to do the job),
Or age (as defined by law).
All applicants may email application to , faxed to
(806) 349-9108 or they may be mailed to HerefordRegionalMedicalCenter
540 WEST 15TH STREET, Hereford, TX 79045 Attn: Human Resources Dept.
We appreciate your cooperation.
APPLICATION FOR EMPLOYMENT
Position(s) applied for ______Date of application______
Name______
Last First Middle
Address______
Street City State Zip Code
Telephone # (__)_____Mobile/Beeper/______Social Security #______
If you are under 18, and it is required, can you furnish a work permit?...... Yes____ No______
If no, please explain______
Have you ever been employed here before?...... Yes____No______
Are you legally eligible for employment in this country?...... Yes____No______
Date available for work…………………………………………………………………….. ______
Type of employment desired _____Full Time ______Part Time _____Temporary _____Seasonal______
Are you able to meet the attendance requirements of the position?...... Yes___ No____
Have you been convicted of a crime in the last seven (7) years?...... Yes____ No____
If yes, please explain______
Conviction will not necessarily be a bar to employment. Each instance and explanation will be considered in relation to the position for which you are applying.
Driver’s license number if driving is an essential job function______State______
Employment History
Provide the following information for your past four (4) employers, assignments or volunteer activities, starting with the most recent.
From To Employer Telephone
│
Job Title Address City State Zip Code
Immediate Supervisor Summarize the nature of work performed and job responsibilities
Reason for leaving Hourly Rate/Salary
______Start $______Per______Final $______Per______
From To Employer Telephone
│
Job Title Address City State Zip Code
Immediate Supervisor Summarize the nature of work performed and job responsibilities
Reason for leaving Hourly Rate/Salary
______Start $______Per______Final $______Per______
From To Employer Telephone
│
Job Title Address City State Zip Code
Immediate Supervisor Summarize the nature of work performed and job responsibilities
Reason for leaving Hourly Rate/Salary
______Start $______Per______Final $______Per______
From To Employer Telephone
│
Job Title Address City State Zip Code
Immediate Supervisor Summarize the nature of work performed and job responsibilities
Reason for leaving Hourly Rate/Salary
______Start $______Per______Final $______Per______
Skills and Qualifications
Summarize any training, skills, licenses, and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.______
______
Educational Background If Job-Related
______
Name and Location Years Completed Did You Graduate Course of Study
______
High School
______
College Major Degree
______
Other
______
References
1.______
Name Telephone Years Known
2.______(____)______
I UNDERSTAND THAT IF I AM EMPLOYED, ANY MISREPRESENTATION OR MATERIAL OMISSION MADE BY ME ON THIS APPLICATION WILL BE SUFFICIENT CAUSE FOR CANCELLATION OF THIS APPLICATION OR IMMEDIATE DISCHARGE FROM THE EMPLOYER’S SERVICE, WHENEVER IT IS DISCOVERED.
I GIVE THE EMPLOYER THE RIGHT TO CONTACT AND OBTAIN INFORMATION FROM ALL REFERENCES, EMPLOYERS, AND EDUCATIONAL INSTITUTIONS AND TO OTHERWISE VERIFY THE ACCURACY OF THE INFORMTION CONTAINED IN THIS APPLICATION. I HEREBY RELEASE FROM LIABILITY THE EMPLOYER AND ITS REPRESENTATIVES FOR SEEKING, GATHEREING AND USING SUCH INFORMATION AND ALL OTHER PERSONS, CORPORATIONS OR ORGANIZATIONS FOR FURNISHING SUCH INFORMATION.
THE EMPLOYER DOES NOT UNLAWFULLY DISCRIMINATE IN EMPLOYMENT AND NO QUESTION ON THIS APPLICATION IS USED FOR THE PURPOSE OF LIMITING OR EXCUSING ANY APPLICANT FROM CONSIDERATION FOR EMPLOYMENT ON A BASIS PROHIBITED BY LOCAL, STATE OR FEDERAL LAW.
THIS APPLICATION IS CURRENT FOR ONLY 6O DAYS. AT THE CONCLUSION OF THIS TIME, IF I HAVE NOT HEARD FROM THE EMPLOYER AND STILL WISH TO BE CONSIDERED FOR EMPLOYMENT, IT WILL BE NECESSARY TO FILL OUT A NEW APPLICATION.
IF I AM HIRED, I UNDERSTAND THAT I AM FREE TO RESIGN AT ANY TIME, WITH OR WITHOUT CAUSE AND WITHOUT PRIOR NOTICE, AND THE EMPLOYER RESERVES THE SAME RIGHT TO TERMINATE MY EMPLOYMENT AT ANY TIME, WITH OR WITHOUT CAUSE AND WITHOUT PRIOR NOTICE, EXCEPT AS MAY BE REQUIRED BY LAW. THIS APPLICATION DOES NOT CONSTITUTE AN AGREEMENT OR CONTRACT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OR DEFINITE DURATION. I UNDERSTAND THAT NO REPRESENTATIVE OF THE EMPLOYER, OTHER THAN AN AUTHORIZED OFFICER, HAS THE AUTHORITY TO MAKE ANY ASSURANCES TO THE CONTRAR. I FURTHER UNDERSTAND THAT ANY SUCH ASSURANCES MUST BE IN WRITING AND SIGNED BY AN AUTHORIZED OFFICER.
I UNDERSTAND IT IS THIS COMPANY’S POLICY NOT TO REFUSE TO HIRE A QUALIFIED INDIVIDUAL WITH A DISABILITY BECAUSE OF THAT PERSON’S NEED FOR A REASONABLE ACCOMMODATION AS REQUIRED BY THE ADA.
I ALSO UNDERSTAND THAT IF I AM HIRED, I WILL BE REQUIRED TO PROVIDE PROOF OF IDENTITY AND LEGAL WORK AUTHORIZTION.
I REPRESENT AND WARRANT THAT I HAVE READ AND FULLY UNDERSTAND THE FOREGOING AND SEEK EMPLOYMENT UNDER THESE CONDITIONS.
SIGNATURE OF APPLICANT ______DATE ______
AUTHORIZATION RELEASE FORM
As an applicant for a position with HEREFORD REGIONAL MEDICAL
CENTER, I have been requested to furnish information for use in determining
my qualifications. In this connection, I do hereby authorize the release and full
disclosure of any information that you may have concerning my employment
with your company.
I authorize you to release such employment information to those employees and
agents ofHEREFORDREGIONALMEDICALCENTER who require such
information in order to make a decision with respect to any matter pertaining
to my status as an employee.
I hereby release: (company)______, its
employees and anyone acting on company ______
behalf from any and all claims, liability and/or damage of any nature which may
result from furnishing the information requested, including, but not limited to,
claims of negligence.
A photocopy of this release will be valid as an original even though the photocopy
does not contain an original writing of my signature.
This release will expire one (1) year after the date signed.
SSN: ______
Print name: ______
Signature: ______
Date: ______
Name of Company: ______Date:______
Mr./Mrs./Ms./ ______s.s.______
States he/she was employed by you from ______to______
As a ______.
If this applicant has been in your employ, we would appreciate your confidential
Reply to the questions below:
______
- Period employed by you: From ______To ______
position: ______salary: ______
- Reason for leaving: lay off ______resigned ______discharged ______
- Would you re-employ? ______Yes ______No
If no, please explain: ______
______
Please indicate by checking: Excellent Good Fair Poor
Honesty ______
Cooperation ______
Attendance ______
Ability ______
Work Habits ______
Safety ______
______
- Record of accidents: ______
______
______
- Remarks:______
______
______
______
(Signature and title) (Date)
All information will be regarded as strictly confidential. We will be pleased to
Reciprocate at any time.
______
(Applicant Signature) (Date)
AUTHORIZATION OF RELEASE AND DISCLOSE
CRIMINAL CONVICTION RECORDS
Name ______
All other names ever used ______
Current Address ______
Other Addresses, if any, for the last 5 years
______
______
Date of birth ______SSN ______
Drivers License No. ______
To any and all state or federal law enforcement agencies, including but not limited
To Hereford Police Department, DeafSmithCounty Sheriff’s Department, Texas
Department of Public Safety, Texas Rangers, Texas Department of Criminal Justice,
Federal Bureau of Investigation (FBI) and any other law enforcement agency not
Named, but within the United States, as well as all record-keeping offices of any county, parish, state, or of the United States, including the Deaf Smith County Clerk’s
Office and the Deaf Smith County District Clerk’s office:
You are hereby authorized and requested to make available at the request of the
Deaf Smith County Hospital District, dba HerefordRegionalMedicalCenter (HRMC)
Any and all records pertaining to criminal convictions of any kind for the person
Named above, whether felony, misdemeanor or otherwise. The time period would
Include everything in the past up to date you actually check for the records.
A photocopy of this form shall have the same effect as the original.
______
(Date) (Signature)
______
(Print Name)
NOTICE CONCERNING
CRIMINAL CONVICTION RECORDS
You are advised that each employee, volunteer, and applicant for employment
with the Deaf Smith County Hospital District, aba Hereford Regional Medical
Center (HRMC), must authorize HRMC to obtain criminal conviction records
On that individual. You are advised that a criminal conviction does not necessarily
Disqualify an employee, volunteer, or applicant. The offense for which the conviction
was made, the time period of the conviction, type of position with HRMC, and
other relevant factors are all considered in determining qualifications for the
position.
By signing the attached sheet, you authorize HRMC to obtain criminal conviction
Records pertaining to you. Further, by signing this sheet, you agree to list below any
Any or all criminal convictions received, other than for minor traffic offenses,
Specifying the offense, date, and location. A separate sheet of paper should be used
If more space is needed.
______
______
______
By signing this sheet, you further agree to provide any additional information or item
That may be needed in connection with a request for criminal conviction history.
______
Name ______
All other names ever used ______
Current Address ______
Other addresses, if any, for last 5 years ______
Date of Birth ______Social Security No ______
Drivers License No ______
______
(Signature)
______
(Date)
Name of Company: ______Date:______
Mr./Mrs./Ms./ ______s.s.______
States he/she was employed by you from ______to______
As a ______.
If this applicant has been in your employ, we would appreciate your confidential
Reply to the questions below:
______
- Period employed by you: From ______To ______
position: ______salary: ______
- Reason for leaving: lay off ______resigned ______discharged ______
- Would you re-employ? ______Yes ______No
If no, please explain: ______
______
Please indicate by checking: Excellent Good Fair Poor
Honesty ______
Cooperation ______
Attendance ______
Ability ______
Work Habits ______
Safety ______
______
- Record of accidents: ______
______
______
- Remarks:______
______
______
______
(Signature and title) (Date)
All information will be regarded as strictly confidential. We will be pleased to
Reciprocate at any time.
______
(Applicant Signature) (Date)