Employee Application

Name

First Middle Last

Position[s] Applied for

Date

MM slash DD slash YYYY

Personal Information

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Cell Phone

Home Phone

Work Phone

Are you at least 18 years of age?

Yes

May we contact you at work?

Yes

Are you legally eligible for employment in the U.S.?

(Proof of U.S. citizenship or status will be required upon employment)

Yes

Other names used (EX: Maiden name, etc)

Date available for work

Desired salary

What status are you requesting?

Full-Time

Part-Time

PRN

Temporary

What shift[s] will you work?

Day

Evening

Night

Weekends

Have you worked at any MidCoast Health System facilities in the past?

Yes

Are you presently charged with any violations of laws other than traffic violations?

Yes

If yes, please explain

Have you been convicted of a felony within the past seven (7) years?

(The existence of a conviction or pending charge will not necessarily preclude you from employment.)

Yes

If yes, please explain

Do you have family members working at the hospital?

Yes

If yes, name and position

Educational Information

High School

(Name and Location, Years Attended, Graduated (yes or no) Degree/Diploma)

College[s]

(Name and Location, Years Attended, Graduated (yes or no) Degree/Diploma)

Graduate School

(Name and Location, Years Attended, Graduated (yes or no) Degree/Diploma)

Other

(Name and Location, Years Attended, Graduated (yes or no) Degree/Diploma)

Professional References

Please give four names of professional references - No family members

Reference Number 1

(Name, Occupation/Title, Address, Phone Number)

Reference Number 2

(Name, Occupation/Title, Address, Phone Number)

Reference Number 3

(Name, Occupation/Title, Address, Phone Number)

Reference Number 4

(Name, Occupation/Title, Address, Phone Number)

Employment Record

Employment History: Please list all previous employers for whom you have worked during the past five years. Explain any lapses between times when employed. ALL INFORMATION MUST BE COMPLETED FOR THE APPLICATION TO BE CONSIDERED

Company (1)

From Date

MM slash DD slash YYYY

To Date

MM slash DD slash YYYY

Phone

Address

Street Address City State / Province / Region ZIP / Postal Code

Job Title

Duties

Supervisor’s Name

Your Name While Working

Ending Salary

Reason for Leaving

Company (2)

From Date

MM slash DD slash YYYY

To Date

MM slash DD slash YYYY

Phone

Address

Street Address City State / Province / Region ZIP / Postal Code

Job Title

Duties

Supervisor’s Name

Your Name While Working

Ending Salary

Reason for Leaving

Company (3)

From Date

MM slash DD slash YYYY

To Date

MM slash DD slash YYYY

Phone

Address

Street Address City State / Province / Region ZIP / Postal Code

Job Title

Duties

Supervisor’s Name

Your Name While Working

Ending Salary

Reason for Leaving

Additional employer information, if necessary

Please provide the names of machines and/or hospital equipment you are able to operate

(computer, adding machine, X-Ray, etc.)

Typing, approximate WPM

Professional License, Registry or Certification #

Issuing Entity

Issuing State

Renewal Date

Have you ever been discharged from a job or forced to resign?

Yes

May we contact your present employer?

Yes

Resume/CV

Max. file size: 300 MB.

Consent

I hereby state that the information given by me in this application is true in all respects.

I agree that if I am employed and the information is found to be false in any respect, I will be subject to dismissal without notice at any time. I hereby authorize my former employers to release information pertaining to my work record, my work habits and my work performance while employed by them.

In making an application for employment, I understand that an investigative report may be made by a consumer reporting agency to include information as to my general character, general reputation, personal characteristics and mode of living, whichever may be applicable. If such an investigative report is made, I understand that I will receive notice that such a report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.

I understand and agree that any employment handbook which I may receive will not constitute an employment contract, but will be merely a gratuitous statement of the Hospital’s current policies.

I understand that the Hospital reserves the right to require its employees to submit to blood tests or urinalysis for alcohol or drug screen, or to allow inspection of bags (including purses or briefcases) or parcels brought into or taken out of the Hospital. I understand that refusal to submit to a urinalysis, blood test or search, when requested to do so, may result in termination of my employment. Furthermore, I understand that as a part of the pre-employment screening process, I will be required to submit to lab testing, to include a drug screen, and physical examination.

I UNDERSTAND AND AGREE THAT IF I AM OFFERED EMPLOYMENT BY THE HOSPITAL, MY EMPLOYMENT WILL BE FOR NO DEFINITE TERM AND EITHER I OR THE HOSPITAL WILL HAVE THE RIGHT TO TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE. I ALSO UNDERSTAND THAT THIS STATUS CAN ONLY BE ALTERED BY A WRITTEN EMPLOYMENT CONTRACT WHICH IS SPECIFIC AS TO ALL MATERIAL TERMS AND IS SIGNED BY MYSELF AND THE ADMINISTRATOR OR OTHER REPRESENTATIVE OF EL CAMPO MEMORIAL HOSPITAL.

Signature

Date

MM slash DD slash YYYY

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Name

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MidCoast Medical Center – Bellville
44 North Cummings St.
Bellville, TX 77418
979-413-7400

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Educational Information

Professional References

Employment Record

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