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Lao Democratic Republic
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18 Years of Age:
Are you legally eligible for employment in the United States:
I am authorized to work in this country for any employer
I am authorized to work in this country for my present employer only
I require sponsorship to work in this country
My status to work in this country is unknown
Are you able to perform the essential functions of the position(s) that you are applying for with or without accommodation?
Have you ever been convicted of a felony?
(Conviction of a criminal offense will not necessarily preclude your employment.)
If yes, provide details:
If your former employment references or education are under a name other than indicated on this application, please indicate:
Available to Work:
Type of work desired:
Have you ever been terminated or have you resigned in lieu of being terminated?
If yes, please explain:
Highest Education Level:
High School Diploma / GED
Trade or Technical School Diploma
Extracurricular activities while in school:
Member of Professional Organizations:
Honors received, volunteer or community service or other qualifications you have which you feel are related to the position for which you are applying:
Periods of Unemployment:
Your resume can be uploaded in any of the following formats: DOC, DOCX, RTF, PDF, TXT, HTML.
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You can use the text area for a cover letter and any supplementary information you would like to provide about your career goals, availability, best times to contact you, etc.
Please Read Carefully Before Signing - Applicant's Certification and Agreement:
I hereby certify that the information and facts set forth in this application are true, complete and accurate to the best of my knowledge. I understand that any falsifications, misrepresentations or omissions of any facts in this application or other documents submitted for consideration of employment will be cause for denial of employment or immediate termination of employment, if employed regardless of the timing or circumstances of discovery.
I understand that if I am hired this Application becomes a part of my official employment record.
I authorize Memorial Hospital to verify the accuracy of any information provided or known. I hereby authorize any and all schools, employers, references, regulatory boards, courts and any others who have information about me to provide such information to Memorial Hospital and/or any of its employees, representatives, agents or vendors. I release all parties involved in this process from any liability for any and all damage that may result from providing such information.
I understand that if offered a position, I may be required to submit to a pre-employment drug screening and criminal background check as a condition of employment. I further understand that I will be required to complete a pre-employment physical exam. I understand that receipt of unsatisfactory results from, failure to complete as required or any attempt to affect the results of these, will result in the immediate withdrawal of any offer of employment or the termination of employment, if already employed.
I understand that submission of an application does not guarantee employment. I further understand that should an offer of employment be made by In consideration of employment, if offered, I agree to abide by and adhere fully to all rules, regulations, policies and procedures of Memorial Hospital at all times. I further understand that the Company's rules, regulations, policies and procedures may be changed at any time, with or without notice. Memorial Hospital, such offer, whether or not stated, is for employment at will, and that if I accept such offer, my employment may be terminated by either the Company or myself at any time, with or without cause or notice. I understand that none of the documents, policies, procedures, actions, or statements of Memorial Hospital or its employees or representatives used during the hiring process or during my employment may be deemed to be a contract for employment, either actual or implied. I understand that no employee or representative, other than the CEO of Memorial Hospital, has the authority to enter into any agreement contrary to the above and that any such agreement if made shall not be binding unless it is set out in a writing signed by the CEO of Memorial Hospital.
Format: M/D/YY *
Voluntary Equal Opportunity Questionnaire
As an equal opportunity employer, we hire without consideration to race, religion, creed, color, national origin, age, gender, sexual orientation, marital status, veteran status or disability. We invite you to complete the optional self-identification fields below used for compliance with government regulations and record-keeping guidelines.
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Hispanic or Latino
White (not Hispanic or Latino)
Black or African American (not Hispanic or Latino)
Native Hawaiian or Other Pacific Islander (not Hispanic or Latino)
Asian (not Hispanic or Latino)
American Indian or Alaska Native (not Hispanic or Latino)
Two or More Races (not Hispanic or Latino)
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Other Protected Veterans
Armed Forces Service Medal Veterans
Recently Separated Veterans
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