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Dallas County Hospital
Location: Alaska arizona arkansas californiaMontana nebraska nevada new hampshire new jersey new mexico new york north carolina north dakota ohio oklahoma oregon pennsylvania rhode island south carolina south dakota tennessee texasVirginia washington west virgini
Time: 2 months ago
- Job Application
Job Application
POSITION APPLYING FOR: | DATE OF APPLICATION: | ||||||||
PERSONAL | |||||||||
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LAST NAME: | FIRST NAME: | MIDDLE INITIAL: | |||||||
HOME ADDRESS: | |||||||||
CITY: | STATE: | ZIP: | |||||||
PHONE: | US CITIZEN: | OVER 18: | |||||||
HOW DID YOU HEAR ABOUT THIS POSITION? | |||||||||
LIST ANY REASON KNOWN TO YOU WHY YOU MIGHT NOT BE ABLE TO PERFORM CONSISTENTLY AND PROMPTLY ANY OF THE DUTIES: | |||||||||
DATE AVAILABLE: | STARTING SALARY NEEDED: | WILL YOU ACCEPT ANOTHER POSITION?
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WILL YOU ACCEPT SHIFT WORK? | WHICH TYPES OF POSITIONS WILL YOU ACCEPT? FULL TIME PART TIME TEMPORARY | WILL YOU ACCEPT WEEKEND WORK? | |||||||
WERE YOU PREVIOUSLY EMPLOYED AT A DCH FACILITY?
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FRIEND OR RELATIVE WORKING HERE? - NAME, DEPT, RELATIONSHIP: | |||||||||
HAVE YOU EVER BEEN CONVICTED OF A CRIME?
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HAVE YOU EVER BEEN EXCLUDED FROM PARTICIPATION IN ANY FEDERAL OR STATE MEDICARE, MEDICAID OR ANY OTHER THIRD PARTY PAYOR PROGRAM OR HAVE SUCH PENDING ACTION?
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EMPLOYMENT HISTORY
LIST MOST RECENT FIRST; LIST OTHER NAMES WHILE EMPLOYED WITH THESE EMPLOYERS. |
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FROM MONTH: | FROM YEAR: | NAME OF EMPLOYER: | NAME/TITLE OF LAST SUPERVISOR: | ||||||
TO MONTH: | TO YEAR: | ADDRESS: | PHONE: | ||||||
POSITION HELD: | ENDING SALARY: | ||||||||
BRIEFLY DESCRIBE THE WORK YOU PERFORMED: | REASON FOR LEAVING: | ||||||||
FROM MONTH: | FROM YEAR: | NAME OF EMPLOYER: | NAME/TITLE OF LAST SUPERVISOR: | ||||||
TO MONTH: | TO YEAR: | ADDRESS: | PHONE: | ||||||
POSITION HELD: | ENDING SALARY: | ||||||||
BRIEFLY DESCRIBE THE WORK YOU PERFORMED: | REASON FOR LEAVING: | ||||||||
FROM MONTH: | FROM YEAR: | NAME OF EMPLOYER: | NAME/TITLE OF LAST SUPERVISOR: | ||||||
TO MONTH: | TO YEAR: | ADDRESS: | PHONE: | ||||||
POSITION HELD: | ENDING SALARY: | ||||||||
BRIEFLY DESCRIBE THE WORK YOU PERFORMED: | REASON FOR LEAVING: | ||||||||
EDUCATION |
NAME OF SCHOOL | LOCATION | YEARS COMPLETED | DATES | COURSE OF STUDY | GRADUATE | DEGREE |
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ELEMENTARY: | ||||||
HIGH SCHOOL: | ||||||
TRADE: | ||||||
COLLEGE: | ||||||
GRADUATE: | ||||||
PROFESSIONAL: | ||||||
BUSINESS: | ||||||
OTHER: |
PROFESSIONAL LICENSES, REGISTRATION, AND/OR CERTIFICATIONS
DO NOT INCLUDE DRIVERS LICENSE. |
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TYPE | STATE ISSUED | DATE ISSUED | EXPIRES | NUMBER | ELIGIBLE |
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APPLICANT'S CERTIFICATION | |||||
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I certify that all matters contained in this application are true, and that any misleading or false statements would render this application void and would be sufficient cause for immediate dismissal in the event of employment. I understand that this is an application for employment and that no employment contract is being offered. I hereby authorize DCH to investigate all matters contained in this application and to contact prior employers to obtain any and all information related to my past performance. I agree, if employed, to abide by all Dallas County Hospital rules and regulations. I understand that such employment is for an indefinite period of time and that the company can change wages, benefits and conditions of employment at any time. I understand that I am required to immediately notify DCH if any action is proposed to exclude me from participation in any federal or state Medicare, Medicaid or third party payor program. I have read and understand the above. |
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DATE: | SIGNATURE: |