Application for Employment
Please fill out the following application in its entirety.

The information you submit in this application is secure and will not be
distributed to anyone outside of the Nacogdoches Memorial Hospital Human Resources department.

Contact Info

Last Name:     First:     Middle: 

E-mail Address: Present Address:      City:  

State:   Zip:   Home Phone: ( ) -

Permanent Address:   

City:    State:    Zip:   Cell Phone: ( ) -

Position Applied For:     Other Positions of Interest

Salary Desired: 

How were you referred to this facility?:

Are you applying for:    Full Time   Part Time   Permanent   Temporary

Relatives or Friends employed in this facility?    Yes    No      Department:     

Date available for work:   

Have you ever been employed by this facility?  Yes    No    When? 

Are you under 18 years of age?    Yes    No      

Would you consider working any shift?    Yes    No            

Weekends & Holidays?  Yes    No   

Rotating Shifts?  Yes    No         

On Call?  Yes    No           

Shift preference:    1st    2nd    3rd 

Have you been the subject of any adverse actions by any duly authorized sanctioning or disciplinary agency?
Yes   No
If yes, please explain

Are you now or have you ever been excluded or debarred from participating with Medicare, Medicaid or any other governmental contract program or service?
Yes   No
If yes, please explain

Are you prevented from lawful employment becuase of your visa or immigration status?
Yes   No
Please indicate visa type or other immigration status, if applicable

Are you nor or have ever been under review for disciplinary actions by any certifying state agency or licensing board?
Yes   No
If yes, please explain

Have you ever been convicted of any criminal violation of law?
Yes   No
If yes, please explain. Include all misdemeanors and felonies.

Have you ever been charged with any criminal violation of law?
Yes   No
If yes, please explain. Include all misdemeanors and felonies.

Are there any investigations pertaining to violation of criminal law pending against you at this time?
Yes   No
If yes, please explain. Include all misdemeanors and felonies.

Education Skills
SCHOOL NAME AND ADDRESS OF SCHOOL COURSE OF STUDY CHECK LAST YEAR COMPLETED DID YOU GRADUATE? DIPLOMA, GED OR DEGREE
HIGH SCHOOL 2
4
Yes
No
COLLEGE 2
4
Yes
No
COLLEGE 2
4
Yes
No

OTHER Business College, Other Special Courses (Include Special Military Training, Post Graduate and Nursing)

Area of Specialization or Major Interest

Typing:  Approx. WPM

Shorthand:  Approx. WPM

List health care, business or industrial equipment operated: 


Professional Information
Are you currently:
Are you eligible for: 
Registered     Licensed     Certified Registration    Licensure    Certification
If Licensed, Registered or Certified:
Type
State Issued
Expiration Date
Number
Type
State Issued
Expiration Date
Number
Type
State Issued
Expiration Date
Number
LANGUAGE SKILLS (where related to position sought)
Language
Speak
Fair  Good   Fluent
Read
Fair   Good   Fluent
Write
Fair    Good    Fluent
Language
Speak
Fair  Good   Fluent
Read
Fair   Good   Fluent
Write
Fair    Good    Fluent

Work History
Please list name, address and phone number of previous employers
with most recent first.
FROM TO SUPERVISOR
LAST SALARY
Hourly, Monthly or Yearly
Job title: 

Employer name, address & phone:       Duties:     

Name employed under: 

Reason for leaving: 

Next employer
FROM
TO
SUPERVISOR
LAST SALARYHourly, Monthly or Yearly
Job title: 

Employer name, address & phone:        Duties:      

Name employed under: 

Reason for leaving: 

Next Employer
FROM
TO
SUPERVISOR
LAST SALARYHourly, Monthly or Yearly
Job title: 

Employer name, address & phone:          Duties: 

Name employed under: 

Reason for leaving: 

State if you do not want us to contact any of the above listed former employers and the reason you do not want each contacted.      


If on your employment history there is a break in your employment for over six months, please explain the reason.


Can we run a detailed employment check, including but not limited to a check with your previous employers?  Yes   No

Did you serve in the U.S. Armed Services?     Yes   No

Have you volunteered your time or services?     Yes   No

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


References
List at least 3 references who are not relatives or employers:
NAME AND RELATIONSHIP
TITLE
COMPANY NAME & ADDRESS
TELEPHONE

Employees of Nacogdoches Memorial Hospital are employed "at will" and may terminate their employment with Nacogdoches Memorial at any time with or without cause.  And in the same respect Nacogdoches Memorial Hospital makes no promise of any kind and remains free to change wages and all other working conditions without consultation and has the absolute authority to terminate employment of any employee with or without good cause. I hereby certify that the information contained in this application form is true and correct and I authorize personnel representatives of this facility to contact any of my schools, former employers or other references unless otherwise stated.  This is to be done for the purposes of collecting information and an account of their experience with me.I understand that if I am employed, any misrepresentation of the facts as stated or implied on this application form is sufficient cause for dismissal.  I also understand that I may be required to successfully complete a medical examination before employment.  This agreement does not bind either party for any specific period regarding employment.
I Agree      I Do Not Agree






An Equal Employment Opportunity Employer.
We comply with all applicable state and federal
civil rights and equal employment laws and regulations.

We comply with all applicable state and federal civil rights and equal employment laws and regulations. We are an equal opportunity employer.

Human Resources department: (936) 568-8543
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