Application for Employment

PERSONAL:

Name:
     First: Middle: Last:
Social Security #: Street Address:
City: State: Zip Code:
E-mail Address:
Home Phone Number: Best Time to Call:
Other phone number where you may be reached:
     Best Time to Call:
Are you under 18? No Yes If yes, date of birth:
Are you legally authorized to work in the U.S.? No Yes
Have you ever worked for Memorial Health Center? No Yes If yes, when?
     Name then (if different):
Are you on layoff, subject to recall? No Yes
How did you find out about this position:
     Newspaper Radio Memorial Health Center Employee —>
     School Internet Other
Briefly explain why you want to work for Memorial Health Center?

Have you ever been convicted of a felony, misdemeanor or other criminal offense (including a civil forfeiture) or are any other criminal charges pending against you? No Yes
If yes, describe in full, including date(s):

(Convictions or pending charges are not an automatic bar to employment unless required by law. Otherwise, the circumstances of the crime will be considered as it relates to the job or if the applicant is not bondable for a job requiring bonding.)

Has it ever been determined by any county that you have abused or neglected a child? No Yes
If yes, describe in full, including date(s):

In the past three years, have you ever knowingly used any illegal narcotics, amphetamines or barbiturates, other than those prescribed to you by a physician? No Yes
If yes, describe in full, including date(s:

GENERAL

Position(s) applied for:
     Job #: Job Title: Date available for work:
Nursing Applicants - please indicate clinical preferences:
     1st: 2nd: 3rd:
Applying for: Full-time (80 hours per pay period) Part-time Temporary Casual What shifts do you prefer? Days PM's Nights
Number of hours desired per pay period:
Wage or salary requirements: $

SKILLS

Clerical Applicants - please complete this section
Typing WPM: List your experience with computers and other office equipment:

All Applicants - please list any additional experiences, skills and qualifications which relate to the job for which you are applying:

EDUCATION

Please list any academic or special awards you have received:

Are you professionally licensed, certified or registered with any professional group, association or society? Yes No
     If Yes, Name of group:
     If Yes, Select: Registration Certification License —> number:
     State: Date of Expiration:

WORK HISTORY

PRESENT OR LAST EMPLOYER

Company Name: Employed From To
Address (street, city, state, zip):
Telephone: Type of Work:
Last Salary: Status: Full Time Part Time
Name of Supervisor: May we contact present employer? Yes No
Reason for Leaving:
Your name then (if different):

NEXT PREVIOUS EMPLOYER

Company Name: Employed From To
Address (street, city, state, zip):
Telephone: Type of Work:
Last Salary: Status: Full Time Part Time
Name of Supervisor: Reason for Leaving:
Your name then (if different):

NEXT PREVIOUS EMPLOYER

Company Name: Employed From To
Address (street, city, state, zip):
Telephone: Type of Work:
Last Salary: Status: Full Time Part Time
Name of Supervisor: Reason for Leaving:
Your name then (if different):

AGREEMENT TO INVESTIGATE AND RELEASE

Read Carefully and Acknowledge by Your Written Signature and Today's Date

I certify that the facts set forth in this application (or any other required documents) are correct, accurate and complete to the best of my knowledge. I understand that falsification, misrepresentation or omission of any facts in said documents will be cause for denial of employment or immediate termination of employment regardless of timing or circumstances. I authorize investigation of the statements I have made.

I release from any and all liability all representatives of Memorial Health Center for their acts performed in good faith and without malice in connection with evaluating my applications, credentials and qualifications. I further authorize any party having information bearing upon my qualifications for employment to release such information to Memorial Health Center (unless otherwise stated). I also release from any and all liability all individuals and organizations who provide information to Memorial Health Center in good faith and without malice concerning my employment competence, ethics, character and other qualifications, including other privileged or confidential information.

I understand that if offered a position at Memorial Health Center, my employment is contingent upon the satisfactory completion of a health examination, drug screen and a criminal record check and investigation of my work record and references. I understand that unsatisfactory results from, refusal to cooperate with, or any attempt to affect the results of employment tests and checks will result in withdrawal of any employment offer or termination of employment if already employed. I consent to a post-offer pre-employment health examination and such future examinations as may be required by Memorial Health Center. I further understand that, if employed, I will serve at least a 90-day probationary period from my date of employment.

I understand that if I am employed by Memorial Health Center, my employment can be terminated by either Memorial Health Center or me at will, with or without cause, and with or without notice, at any time. I understand that no one at Memorial Health Center, other than the President, has the authority to alter, orally or in writing, this terminable-at-will status of employment.

My typed name below shall have the same force and effect as my written signature.

Signature of Applicant:
Date: