Northwest Medical Center

Application for Employment
Position Applied for:
How did you learn about us?

Last Name:	First Name:	Middle Initial:
Address:
City:
State:	Zip:	Phone:
Social Security Number:	For security reasons, we will contact you for your social security number.

The best time to contact you at home is:
If you are under 18 years of age, can you provide required proof of you eligibility to work?
Have you ever applied with us before?
If so, give date:
Have you ever been employed with us before?
If so, give date:
Do any of your friends or relatives, other than spouse, work here?
Are you currently employed?
May we contact your present employer?
Are you prevented from lawfully becoming employed in this country because of Visa immigration status? Proof of citizenship or immigration will be required upon employment
Date available for work: mm/dd/yyyy
What is your desired salary range?	$
Are you availible for work:	Full-Time indicate
	Part-Time indicate
	Temporary indicate dates
Are you currently on "lay-off" status and subject to recall?
Can you travel if a job requires it?
Have you been convicted of a felony within the last five years? (A criminal record does not constitute an automatic bar to employment and will be considered as it relates to the job in question)

Education
	Name and Address	Course of Study	Years Completed	Diploma Degree
Elementary School
High School
Undergraduate College
Graduate Professional
Other (specify)

Describe any specialized training, apprenticeship, skills and extra-curricular activites.

Describe any job-related training received in the United States military.

Employment Experience

Employer

Dates Employed
From	To

Hourly Rate/Salary
Starting	Final

Work Performed:

Address

Phone Number

Job Title

Supervisor

Reason for Leaving

Employer

Dates Employed
From	To

Hourly Rate/Salary
Starting	Final

Work Performed:

Address

Phone Number

Job Title

Supervisor

Reason for Leaving

Employer

Dates Employed
From	To

Hourly Rate/Salary
Starting	Final

Work Performed:

Address

Phone Number

Job Title

Supervisor

Reason for Leaving

Employer

Dates Employed
From	To

Hourly Rate/Salary
Starting	Final

Work Performed:

Address

Phone Number

Job Title

Supervisor

Reason for Leaving

List professional, trade, business or civic activities and offices held.
You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status.

Other Qualifications
Summarize special job-related skills and qualifications acquired from employment or other experience.

Specialized Skills (Check Skills/Equipment Operated)

Terminal	Production/Mobile Machinery	Other
PC/Mac
Typewriter
WPM
Spreadsheet
Word Processing
Shorthand
WPM

State any additional information you feel may be helpful to us in considering your application.

Note to applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? A review of the activities involved in such a job or occupation has been given.

References
1.	Name	Phone
	Address

2.	Name		Phone
	Address

3.	Name		Phone
	Address

Applicant's Statement

I certify that answers given herein are true and complete.

I authorize investigation of all statments contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at this time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at anytime with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Name of Applicant	Date