Nacogdoches Memorial Hospital - Where People Come First

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.

Last Name:    First:     Middle: Social Security No.: - -

E-mail Address: Present Address:     City:

State: Zip: Phone: ( ) - Permanent Address:

City: State: Zip: Phone: ( ) -

Position Applied For:    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.

SCHOOL	NAME AND ADDRESS OF SCHOOL	COURSE OF STUDY	CHECK LAST YEAR COMPLETED	DID YOU GRADUATE?	DIPLOMA, GED OR DEGREE
HIGH SCHOOL			1 2 3 4	Yes No
COLLEGE			1 2 3 4	Yes No
COLLEGE			1 2 3 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:

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

Please list name, address and phone number of previous employers with most recent first.	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:
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)

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