In accordance with the Drug Workplace Act of 1988, Morgan Memorial Hospital will not tolerate the usage of illegal drugs or alcohol in the work place. Morgan Memorial Hospital requires all employees to pass a pre-employment drug screen,a criminal records check, a credit check and a motor vehicle license check. Morgan Memorial Hospital is an equal opportunity employer.

Personal Information:

Date: Sep-08-2010

Current Address:


Job Information:

Type Desired:

What shift are you willing to work?

 Are you willing to work weekends and or holidays?
7P/7A
3P/11P 7A/7P
8A/4:30P 8:30A/5P  
11P/7A Weekend Option  

When will you be available for work?

List each place you have lived in the past 5 years:

Location 1:
From: Date Year(yyyy)
To: Date Year(yyyy)


Location 2:
From: Date Year(yyyy)
To: Date Year(yyyy)

Location 3:
From: Date Year(yyyy)
To: Date Year(yyyy)

Skills/Qualifications

Please list skills and/or supervisory qualifications that would correspond with the position applied for:

List additional skills or experience:

Additional Personal Information

Are you 18 years of age? Yes (Workers permit required if under 18 years of age)

Are you a U.S. Citizen or an Alien Legally authorized to work in the United States? Yes
If NO, type of Visa:

Have you ever been convicted of a Felony?
If "yes," please explain thoroughly:

Are you related to anyone employed at Morgan Memorial Hospital?
If "yes," who?

How were you referred to apply?

Education

Number of years completed in high school: 1 2 3 4
Name of School: City: State:
High School Diploma: G.E.D.?

Number of years completed in college: 1 2 3 4 5 6 7 more
School: City: State:
Major: Degree Earned:

If you hold a PROFESSIONAL LICENSE, REGISTRATION, or CERTIFICATION, please indicate:
Type: No.: State:
Expiration Date: Date Year(yyyy)

Employment History

Give complete records oaf all employment and/or reason for periods of unemployment during the past 10 years. Begin with most recent employer.

From: Date Year(yyyy)
To: Date Year(yyyy)
Employer:


Telephone:
Salary: Position:
Reason for leaving:

From: Date Year(yyyy)
To: Date Year(yyyy)
Employer:


Telephone:
Salary: Position:
Reason for leaving:

From: Date Year(yyyy)
To: Date Year(yyyy)
Employer:


Telephone:
Salary: Position:
Reason for leaving:

From: Date Year(yyyy)
To: Date Year(yyyy)
Employer:


Telephone:
Salary: Position:
Reason for leaving:

From: Date Year(yyyy)
To: Date Year(yyyy)
Employer:


Telephone:
Salary: Position:
Reason for leaving:

May we contact the employers listed above? If not, please indicate the employers we may contact:

References:

(1 Personal required and 2 work/professional required)

First Name: Last Name: Occupation / Organization:
Phone Number: Address:

First Name: Last Name: Occupation / Organization:
Phone Number: Address:

First Name: Last Name: Occupation / Organization:
Phone Number: Address:

Plain text resume or additional information not included in this application:

Statement of Understanding/Consent:

I authorize Morgan Memorial Hospital and/or their authorized representative, to investigate my references and previous work history as indicated above and release such individuals, companies or institutions and MMH from any and all liability for any damage whatsoever incurred by furnishing such information. I understand that incorrect information on this application may be grounds for immediate dismissal. I understand that MMH will require a pre-employment Criminal Background Check, Drug Screen, and Employee Health screens and that I may not begin working at MMH until all of these requirements are successfully completed.

All applications will be reviewed by Human Resources and the hiring manager. Applicants will be contacted directly if chosen for an interview.

By printing your name in this text field and submitting this application you agree that you have read and understand the "statement of understanding/consent."

Print your full legal name here:

Your information will be sent to us upon "Submit" - you can print the next screen for your records. Thank you for your application.