Gilbert Hospital - Gilbert, Arizona .:. Job Application

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Job Application

GILBERT HOSPITAL
APPLICATION FOR EMPLOYMENT
An Equal Opportunity Employer

Personal Information

First Name:
M.I.
Last Name:
Email:

Address:
City:
State:
Zipcode:
Phone:

Are you at least 18 years of age? Yes No

Have you ever been convicted of a crime(s) other than a minor traffic violation? Yes No

If yes, explain (nature of the crime, where, when, and disposition):

General Information

Position applied for:
Salary Desired:	Date available to work:
If you are currently employed, may we contact your employer? Yes No
Have you ever worked for Gilbert Hospital before? Yes No
If yes, when?
Have you previously applied for employment with us? Yes No
If yes, when?
List any relatives employed by Gilbert Hospital:
Why do you desire a job change?

Education Information

	School Name	Location	Degree Date
Grade School
High School
College
Graduate School
Trade School

List any acedemic, professional, trade, social, or civic activities, offices held, or other accomplishements:

Military Information

Branch: Date of Entry: Date of Discharge:
Rank at Discharge:
Describe your Duties:
Was your discharge related to criminal charges? Yes No
If yes, explain fully?

Skills

Check the areas in which you have working knowledge:

Computer Software:
Word Perfect
Microsoft Office
Lotus
Other:

Type:	Yes No WPM:
Shorthand:	Yes No WPM:
Ten Key by Touch:	Yes No
Dictation Machine:	Yes No
Other Office Equipment:

Describe any other skills or aptitudes that you feel would qualify you for a position with Gilbert Hospital:

References

List three (3) business, professional, persons who can attest to your work capabilities
(Do not include relatives or former employees).

	Name	Address	Phone	Occupation
1
2
3

Notification

In the event of an emergency, notify the following persons:

	Name	Address	Phone	Relationship
1
2
3

Employment Eligibility Status

Are you lawfully eligible to be employed in the United States? Yes No
(Proof of citizenship or immigration status is required upon employment)

Employment History

List all of your previous employment below, going back at least 10 years. If you have been self-employed, give details such as name of the company, location, and why business was discontinued. Begin with your most recent employer and end with the oldest.

Company 1

Company:		Type of Business:
Address:		Phone:

Date Started:

Date Left:

Position:

Supervisor's Name:		Rate of Pay:
Description of Duties:
Reason for Leaving

Company 2

Company:		Type of Business:
Address:		Phone:

Date Started:

Date Left:

Position:

Supervisor's Name:		Rate of Pay:
Description of Duties:
Reason for Leaving

Company 3

Company:		Type of Business:
Address:		Phone:

Date Started:

Date Left:

Position:

Supervisor's Name:		Rate of Pay:
Description of Duties:
Reason for Leaving

Please explain any periods of time which you were unemployed:

Have you ever been dismissed or asked to resign from a previous job? If yes, explain:

Gilbert Hospital
Voluntary Disclosure Form (EEOC)

It is the policy of Gilbert Hospital to provide equal employment opportunity to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, handicap, or veteran's status; or status within any other protected group. Various agencies of the United States government require employers to collect information about applicants. Information requested on this sheet is for the purposes of compliance regarding your application for employment. This sheet will be kept confidential and maintained separately from your application form. Completion of this sheet is voluntary and is not a requirement for employment.

First Name:
M.I.:
Last Name:
Position Applied For:

Referral Source (hold ctrl to select multiple):

Other:

What is your Race?

White
Black
Hispanic
Asian/Pacific Islander
American Indian or Alaskan Native
What Is Your Sex?
Male
Female

Are You Handicapped? Yes    No
(Yes indicates you have a physical pr mental impairment which substantially limits a major activity or have a history of such impairment)

Are You a Disabled Veteran? Yes    No
(Yes indicates you are entitled to disability compensation under law administered by Veterans Administration for disability rated 30% or more OR discharged/released from active duty for disability incurred or aggrevated in the line of duty)

Are You a Special Disabled Veteran? Yes    No
(Yes indicates you were discharged/released from active duty because of service connected disability OR entitled to disability compensation [or who, but for receipt of military pay, would be entitled to disability compensation] for a disability [1] rated at 30% or more, or [2] rated at 10% or 20% and under 38 U.S.C 1506 has been determined to have a serious employment handicap)

Submission of this application implies your agreement with our Application Agreement.
It should be read carefully before submitting.