* indicates required information.
First Name *
Middle Name
Last Name *
Street Address *
City *
State *—Please choose an option—AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming
Zip Code *
E-mail Address *
Home Phone Number *
Work Phone Number
Are you at least 18 years of age? *YesNo
Position Applied for *
Shift Preferred *DayEveningNight
Position Status *Full-TimePart-TimeOn CallSeasonal
Date Available to Start *
Have you ever worked at Lakeview Methodist before? *YesNo
When? *
Dept? *
Supervisor? *
Reason for leaving? *
How did you learn of this job opportunity?—Please choose an option—AdvertisementEmployeeWalk-InWebsiteInternal PostingEmployment Agency
For purposed of compliance with The Immigration and Control Act, are you legally eligible for employment in the United States? *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.
High School Name
Address
Course of Study
Last Year Completed9101112
Did you graduate?YesNoStill Attending
College/University Name
Course of Study/Degree
Last Year Completed1234
Tech/Business Name
Other Education Name
If you expect to complete an education program in the near future, please indicate what type of degree or program and expected completion date
Check items at which you are skilled.SwitchboardFax MachineCalculating MachineComputer/WPMSoftware used (Please indicate type used below)Other (Please specify below)
WPM
Software
Other
Select One *RNLPNNA/REGNone
List RN License Number *
States Registered as RN *AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming
RN License Expiration Date *
List LPN License Number *
States Licensed as LPN *AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming
LPN License Expiration Date *
List certification *
Certification States *AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming
Are you on the registry? *YesNo
Length of course *3084Other (Specify)
Number of hours *
List complete employment history starting with last employer first.
Name
Telephone
Job Title
Supervisor
Reason for leaving
Dates Employed - From
Dates Employed - To
StatusFull-TimePart-Time
Work performed
Add?YesNo
May we contact your present employer? *YesNoNot at this time
Which of these jobs did you like the best and why?
Which of these jobs did you like the least and why?
Please describe your work interest and/or career goals.
Special Skills/Training that may be useful in evaluating you for employment.
Give the names of three non-relatives whom you have known for at least one year.
Name *
Phone *
Address *
Years Acquainted *
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.
Applicant's Signature *
Date Signed *
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