Online Application Form

Position(s) Applied For

Date of Application

How Did You Learn About Us?
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Contact Information

Last Name  First Name  M.I.

Street Address 

City  State --state-- AL AK AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY  ZIP 

Phone Social Security Number (voluntary)

Email

Are you at least 18 years of age?

Yes
No

Have you ever been employed with us before?

Yes
No

If Yes, give date:

After being hired, will you be able to document your eligibility to work in the United States?

Yes
No

Have you ever been convicted of a crime?

Answering yes will not automatically disqualify you, but you must provide details of the conviction. Failure to disclose information that appears on a post-offer, pre-employment background check will result in the removal of the job offer, if extended.

Yes. If yes, please explain.
No

Date Available for Work Desired Salary Range

Are you available to work:

Full Time (Please indicate 1 2 3 shift )
Part Time (Please indicate: Morning Afternoon Evenings )
Temporary (Please indicate dates available to

School Name

Did you graduate?

Address

Diploma/Degree

High
School

Yes No

Undergrad
College

Yes No

Grad/
Professional

Yes No

Other
(specify)

Yes No

Employer:

Dates Employed:

Employer Name

From (mo/yr)

To (mo/yr)

Address

Hourly Rate/Salary:

Phone

Starting:

Final:

Supervisor Name

Work Performed:

Starting/Present Job Title

May We Contact?

Yes
No

Reason for Leaving:

Employer:

Dates Employed:

Employer Name

From (mo/yr)

To (mo/yr)

Address

Hourly Rate/Salary:

Phone

Starting:

Final:

Supervisor Name

Starting/Present Job Title

May We Contact?

Yes
No

Reason for Leaving:

Employer:

Dates Employed:

Employer Name

From (mo/yr)

To (mo/yr)

Address

Hourly Rate/Salary:

Phone

Starting:

Final:

Supervisor Name

Work Performed:

Starting/Present Job Title

May We Contact?

Yes
No

Reason for Leaving:

Name

Company

Relationship

Phone Number

1. I authorize the investigation of any and all statements contained in this application. I also authorize, whether listed or not, any person, company, school, current employer, past employer or person to give any relevant information and opinions regarding my employment, education, character, and qualifications that may be useful in making a hiring decision and hereby release them from all liability for any damages as a result of providing this information.

2. I certify that all my statements and information related to the employment process, application, and resume, are true and complete; failure to answer any question, or failure to answer truthfully and completely may result in my not being hired or in being terminated after discovery.

3. If hired, I would be an at-will employee and Howard County Community Hospital and Medical Clinic or I can terminate my employment at any time, with or without cause.

4. All job offers are contingent upon the review of references, background checks, drug/alcohol screening, and other relevant job information. Any misleading or incorrect statements, omissions or failure to disclose any criminal convictions, health care related convictions, or any threatened or actual disbarment, exclusion or other ineligibility of participation in federallly funded health care programs, may remove this application from further consideration for employment, and if employed, may be cause for termination. Disabled applicants who cannot perform the essential functions of the job with reasonable accommodation will not be eligible for the position applied for.

Please check to verify that you have read and agree to the conditions above: