* indicates required information.

Personal Information
Full Legal Name

Present Address

YesNo

Employment Desired

DayEveningNight

Full-TimePart-TimeOn CallSeasonal

YesNo

YesNo
**Under the Immigration Reform and Control Act of 1986, you will be required to fill out a certification verifying that you are eligible to be employed and verifying your identity. Further, you will be required to provide documentation to that effect should you be employed.

Education
High School

9101112

YesNoStill Attending

College University

1234

YesNoStill Attending

Tech/Business School

1234

YesNoStill Attending

Other Education School

1234

YesNoStill Attending

Clerical Applicant Only

SwitchboardFax MachineCalculating MachineComputer/WPMSoftware used (Please indicate type used below)Other (Please specify below)

Licenses & Certifications

RNLPNNA/REGNone

RN

LPN

NA/REG

YesNo

3084Other (Specify)

Employment History

List complete employment history starting with last employer first.

Employer 1

Full-TimePart-Time

Employer 2

Full-TimePart-Time

Employer 3

Full-TimePart-Time

Employer 4

YesNo

Full-TimePart-Time

Employer 5

YesNo

Full-TimePart-Time

YesNoNot at this time

References

Give the names of three non-relatives whom you have known for at least one year.

First Reference

Second Reference

Third Reference

Applicant Release

Read before you sign.

I understand and agree that any offer of employment is conditional upon completing and passing medical screening based on the physical demands of the job for which I am applying, acceptable reference checks, criminal background check, and successful completion of the orientation period.

I authorize Lakeview Methodist Health Care Center to investigate all statements contained in this application and I understand that misinformation given on my employment application form and during the medical screening is sufficient cause of termination, if I am employed.

I understand that nothing contained in this employment application or the granting of an interview or in any policies, procedures, and handbooks I might receive, is intended to create an employment contract between Lakeview Methodist Health Care Center and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon Lakeview Methodist Health Care Center. If an employment relationship is established, I understand that I have the right to terminate my employment at any time, for any reason, and Lakeview Methodist retains a similar right regarding the termination of my employment.