| Application for Employment |
Positions applied for:
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Application Date: (mm/dd/year)
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Expected Salary:
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| Type of employment you are looking for: |
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Part-time
Full-time
Temporary
Casual
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| Are you willing to work all shifts? |
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Yes No |
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If not, select shifts that are NOT acceptable:
(Hold shift key for multiple selections) |
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If your application is considered favorably,
on what date will you be available to work? |
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(mm/dd/year) |
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| Were you previously employed by us? |
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Yes No
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| If so, when? |
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(mm/dd/year) |
How were you referred to
Ohio Valley General Hospital? |
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| Personal Information |
Full Legal Name: (Last Name, M.I., First Name)
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Other, or previously used names:
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Current Address: (Include: City, State, Zip)
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Telephone Number:
Ex. 123-456-7890 |
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Alternate Telephone Number*:
Where you can be contacted during normal business hours or where a message can be left for you. |
Email Address:
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| Are you 18 years of age or older? |
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Yes No
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| Have you ever pled guilty or been convicted of a crime other than a misdemeanor or summary offense? |
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Yes No
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If yes, explain:
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List any relatives who work for Ohio Valley General Hospital:
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| Education |
| High School (Number of Years): |
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1 2 3 4 |
Name of School:
Received Diploma
Received G.E.D.
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City:
State:
Zip:
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| College (Number of Years): |
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1 2 3 4 |
Name of School:
Degree:
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City:
State:
Zip:
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| Other Training or Degrees |
Other School(s) Attended:
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City:
State:
Zip:
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Course of Study:
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Diploma/Degree Earned/Expected:
Year Earned:
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Please list your current employment license, registration or certification number(s):
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From which state/commonwealth or accrediting organization?
Expiration date, if any:
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Please state any training, experience, education, or any other facts which particularly qualify you for the job(s) for which you are applying. Include capabilities on any business machines:
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| Employment: (List current or most recent first. Include military
history.) |
| From:
To: (mm/dd/year) |
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Salary: |
Employer Name, Address w/Zipcode & Phone Number:
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Position & Duties:
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Reason for leaving:
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| From:
To: (mm/dd/year) |
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Salary: |
Employer Name, Address w/Zipcode & Phone Number:
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Position & Duties:
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Reason for leaving:
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| From:
To: (mm/dd/year) |
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Salary: |
Employer Name, Address w/Zipcode & Phone Number:
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Position & Duties:
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Reason for leaving:
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| From:
To: (mm/dd/year)
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Salary: |
Employer Name, Address w/Zipcode & Phone Number:
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Position & Duties:
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Reason for leaving:
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| Are you currently employed? |
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Yes No |
| May we contact your current employer? |
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Yes No |
| May we contact all other employers listed? |
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Yes No |
| Have you ever been discharged by a previous employer? |
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Yes No |
If yes, explain:
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If the job(s) for which you are applying
require(s) a bond, state if you have ever
been bonded: |
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Yes No |
If you have been bonded, list the jobs for which you were bonded:
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If you have ever been refused a bond, please describe in detail:
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