GORDON MEMORIAL HOSPITAL APPLICATION FOR EMPLOYMENT FEDERAL LAW OBLIGATES US TO PROVIDE REASONABLE ACCOMMODATION TO THE KNOWN DISABILITIES OF APPLICANTS AND EMPLOYEES, UNLESS TO DO SO WOULD POSE AN UNDUE HARDSHIP. PLEASE FEEL FREE TO LET US KNOW IF YOU NEED AN ACCOMMODATION TO COMPLETE THE APPLICATION PROCESS OR TO PERFORM ANY ESSENTIAL ELEMENTS OF THE POSITION SOUGHT. Applicants are considered for all positions, and employees are treated during employment, without regard to race, color, religion, sex, national origin, age, disability or any other prohibited basis of discrimination, as provided under applicable state and federal law. Date Postion Applied For Referral Source (Ad/Friend/Other) Last Name First Name Middle Name Soc. Sec. # Address Line 1 Address Line 2 City State Zip Code Country Daytime Phone () - Evening Phone () - E-mail Address Emergency Contact Contact Phone Have you applied here before? Application Date Have you been employed here before? Employment Dates Are you employed now? May we contact your employer? What date are you available for work? Are you avialable for (Full Time/Part Time/Temp)? Are you on lay-off subject to recall? Are you 18 years of age or older? Veteran of U.S. Military? Branch of Service Highest level of education Where List Duties or Special Training Current or most recent employer Employer 1 address Employer 1 phone () - Job Title 1 Employer 1 Supervisor Employer 1 dates employed Employer 1 work performed Employer 1 Reason for leaving Employer 2 Employer 2 Address Employer 2 Phone () - Job Title 2 Employer 2 Supervisor Employer 2 dates employed Employer 2 work performed Employer 2 Reason for leaving Employer 3 Employer 3 address Employer 3 phone () - Job Title 3 Employer 3 Supervisor Employer 3 dates employed Employer 3 work performed Employer 3 Reason for leaving Employer 4 Employer 4 address Employer 4 phone () - Job Title 4 Employer 4 Supervisor Employer 4 dates employed Employer 4 work performed Employer 4 Reason for leaving If hired, you will be required to submit documents sufficient to establish employment authorization and identity in compliance with the Immigration Reform and Control Act of 1986. While you need not provide this proof of citizenship or immigration status at the time you are interviewed, please be prepared to assure us that you can do so immediately upon being hired. APPLICANT’S STATEMENT These answers are true and complete to the best of my knowledge. The Gordon Memorial Hospital may investigate all statements contained in this application and I understand that any false or misleading information provided during the application or interview process will result in my immediate discharge if I am hired, regardless of when discovered. I UNDERSTAND THAT THIS APPLICATION IS NOT A CONTRACT OF EMPLOYMENT. I ALSO UNDERSTAND THAT IF HIRED, REGARDLESS OF ANY ORAL REPRESENTATIONS TO THE CONTRARY, THE EMPLOYMENT RELATIONSHIP BETWEEN MYSELF AND THE COMPANY IS TERMINABLE – AT – WILL SO THAT BOTH THE COMPANY AND I REMAIN FREE TO CHOOSE TO END OUR WORK RELATIONSHIP AT ANY TIME FOR ANDY OR NO REASON. ANY CHANGES IN THIS EMPLOYMENT RELATIONSHIP MUST BE MADE IN WRITING. I also understand that any offer of employment may be conditioned upon a health evaluation by a doctor selected by the Gordon Memorial Hospital to determine whether I can perform the job duties. I authorize the Gordon Memorial Hospital to make a thorough investigation of my past employment, education and job – related activities and I release from all liability all persons, companies and corporations supplying such information. I also in demnify the Gordon Memorial Hospital against any liability which might result from making such investigation. Additionally, I authorize the Gordon Memorial Hospital to supply my employment record, in its sole discretion, in whole or in par, to any prospective employer, government agency or other party with an interest that the Gordon Memorial Hospital deems appropriate.