Apply – Fairfield Memorial Hospital

Personal Information

Name *

First

Middle

Last

Any previous names? *

Yes
No

If yes, please identify all other names including maiden name *

Present Address *

Address Line 1

Address Line 2

City

State

Zip Code

Permanent Address (if different than Present Address above)

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Contact Phone *

Email Address *

Best time to contact you?

Start Date Availability

When would you be able to start work?

Would you consider working (check all that apply)

Full Time - Regular
Full Time - Temporary
Part Time - Regular
Part Time - Temporary

Would you consider working (check all that apply)

Weekends and Holidays
Rotating Shifts
On Call
Any Shift

Shift Availability (check all that apply)

Days
Evenings
Nights

Position Applying for

How did you learn about this position?

Relatives or friends employed at this facility? *

Yes
No

Have you ever been employed at this facility? *

Yes
No

Are you 18 years of age or older? *

Yes
No

Are you a U.S. citizen or an alien legally authorized to work in the United States? *

Yes
No

Describe your long range occupational goals

Have you ever been involved in the substantiated abuse or neglect of children or adults under the laws of this or any other state of the United States? *

Yes
No

Abuse/Neglect: If yes, which state(s), and explain

If yes, which state(s), and explain

Have you been sanctioned, cited, reported, or excluded from participation in Medicare, Medicaid, or any other healthcare related law or regulation? *

Yes
No

Sanctioned/cited: If yes, explain

If yes, explain

Education Information

Enter your highest level of education completed

Type of School

High School
College
Other

Name of School

Address

Address Line 1

Address Line 2

City

State

Zip Code

Course of Study

Last year completed?

1
2
3
4

Did you graduate?

Yes
No

List diploma or degree:

Other Education/Experience

Other Business, College or Special Courses

Include Special Military Training, Post Graduate and Nursing

Area(s) of specialization or major interest

List health care, business, or industrial equipment operated

List office skills

Include computer, software experience

Word Processing Experience

Include approximate WPM

Licenses

Professional Licenses

Type

State

Number (#)

Date

Additional Licenses and Information

Professional Certifications

N/A
Currently Certified
Eligible for Certification

Type

State

Date

Military or Volunteer Experience

Briefly describe duties and skills acquired through military or volunteer service. Please include dates.

Previous Experience

Previous Jobs

Provide information regarding previous employment, beginning with most recent employer.

Employer Name

Job title

Job Duration

Start date through end date

Supervisor name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Duties

Reason for leaving

(2) Employer Name

(2) Job title

(2) Job Duration

Start date through end date

(2) Supervisor name

(2) Address

Address Line 1

Address Line 2

City

State

Zip Code

(2) Duties

(2) Reason for leaving

(3) Employer Name

(3) Job title

(3) Job Duration

Start date through end date

(3) Supervisor name

(3) Address

Address Line 1

Address Line 2

City

State

Zip Code

(3) Duties

(3) Reason for leaving

References

List at least three (3) professional / work / school references who are not relatives or personal acquaintances

Reference #1

Include Name/Relationship, Title, Company Name, Phone, and Addresses

Reference #2

Include Name/Relationship, Title, Company Name, Phone, and Addresses

Reference #3

Include Name/Relationship, Title, Company Name, Phone, and Addresses

Upload Your Resume

Click or drag a file to this area to upload.

Upload your resume here to attach it to your application. Maximum file size is 10MB.
Allowed extensions: .txt, .doc, .docx, .pdf, or .rtf

Review & Submit

I hereby affirm that the information provided on this application (and accompanying resume, if applicable) is true and complete. I understand that any false or misleading representations or omissions made on the application or during the hiring process may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date. I understand that employment may be conditioned upon successfully passing a medical examination and that I may be required to satisfactorily complete a drug screening as a condition of employment. I hereby authorize persons, schools, my current employer (if applicable) and previous employers and other organizations to provide the facility and its affiliates with any requested information regarding my application or suitability for employment, and I completely release all such persons or entities from any and all liability related to the providing or use of such information. I understand that, if selected for employment at Fairfield Memorial Hospital, my employment is at-will, which means that I may terminate the employment relationship at any time and for any reason with or without notice, and that the facility has the same right. I understand that no one has the authority to enter into any agreement contrary to the preceding sentence, except for a written agreement signed by an administrative representative of this facility notarized. I also acknowledge and, if selected for employment at Fairfield Memorial Hospital, agree to abide by the facility's tobacco-free policy. I have read and agree to the terms above and authorize my application with my signature below: *

Accept
Decline

Name *

Please enter your full name to sign this form

Date

MM/DD/YY

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