Application for Employment

Last Name: First Name:
Middle Name: Social Security Number:
City/Town: Address:
State: County:
Phone: Zip Code:
Cell:    
Please list any friends or relatives working for Monongahela Valley Hospital by name and relationship:
Have you ever been convicted of a misdemeanor or felony?
If yes, describe and list dates: Yes No
Military Service, Date, Grade:
Position applied for: When you can start:
Full Time Part Time If part time - hours you can work per week:
Have you applied or worked for us before? Yes No When:
Education    
Name of School Location From
month
year		 To
month
year 		Course Graduation Degree Major Field
Professional Licenses and/or Certifications    
Are you currently:
Registered Licensed Certified		 Type State Issued Date No.
Eligible for:
Registration Licensure Certification		 Type State Issued Date No.
Personal References List below two persons, excluding relatives or former employers,
who have known you for five years.
Name Address Phone No. Years Known
Work History List Below the names of all employers,
beginning with the most recent:
Name Address Phone Kind of Business Employed
From
T o		 Position & Duties Salary
Start
Final 		Reason for Leaving Name & Title of Supervisor
May we contact your present employer? Yes No    

I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I also agree that any falsified information or significant omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date.

I authorize a thorough investigation of my past employment and activities, agree to cooperate in such investigation, and release from all liability of responsibility all persons and corporations requesting or supplying such information. To the fullest extent permitted by law. I further authorize any physician or hospital to release any information which may be necessary to determine my ability to perform the essential functions of the job to which I am being considered or any future job in the event that I am hired.

I hereby agree to submit to any lawful drug, alcohol, or integrity testing that may be required as a condition of employment or continued employment and understand that refusal to submit to such testing during the course of my employment may result in disciplinary action, up to and including discharge.

I understand that any offer of employment is contingent upon satisfactorily completing the hospital’s pre-employment assessment.

I hereby release Monongahela Valley Hospital, Inc. and all my references and former employers from any liability for any damage due to releasing information regarding me.

Enter your full name to act as your signature: Date: 5/15/2008

(please click only once, it may take a moment to process)		    
MONONGAHELA VALLEY HOSPITAL IS AN EQUAL OPPORTUNITY EMPLOYER AND DOES NOT
DISCRIMINATE BECAUSE OF RACE, COLOR, RELIGION, SEX, AGE, NATIONAL ORIGIN OR DISABILITY.