Pushmataha Hospital - Application for Employment

Name:*
Address:
Phone:*
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E-mail:*
Driver's License Number:
Position Applying For:
Please list licensing/training pertaining to your job request:
Type of Employment Desired:
Date you will be available to start work:
Are you able to meet the attendance requirements?:
Do you have any objection to working overtime if necessary?:
Have you ever been previously employed by our organization?:
Can you submit proof of legal employment authorization and identity?:
Do you have a medical condition that will affect your work performance?:
If yes, please explain:
Have you ever been convicted of a felony?:
If yes, please explain previous felony:
How were you referred to us?:
If you are under 18, can you furnish a work permit if it is required?:
Previous Employer #1:
Previous Employer #1 Address:
Previous Employer #1 Phone:
Previous Employer #1 Immediate Supervisor and Title:
Previous Employer #1 Dates Employed:
Previous Employer #1 Last Salary:
Previous Employer #1 Job Summary:
Previous Employer #2:
Previous Employer #2 Address:
Previous Employer #2 Phone:
Previous Employer #2 Immediate Supervisor and Title:
Previous Employer #2 Dates Employed:
Previous Employer #2 Last Salary:
Previous Employer #2 Job Summary:
Previous Employer #3:
Previous Employer #3 Address:
Previous Employer #3 Phone:
Previous Employer #3 Immediate Supervisor and Title:
Previous Employer #3 Dates Employed:
Previous Employer #3 Last Salary:
I hereby authorize the potential employer to contact, obtain and verify the accuracy of information contained in this application, including but not limited to: achievement, wage history, performance, attendance, personal history, disciplinary information, and reason for separation of employment, from all previous employers, educational institutions and references. I also hereby release from liability the potential employer and it representatives for seeking, gathering and using such information to make employment decisions and all other persons or organizations for providing such information. I further authorize the potential employer to verify my Criminal History Record. I understand that any misrepresentation or material omission made by me on this application will be sufficient cause to cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered. If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or the employer can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law. I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that person’s need for a reasonable accommodation as required by the ADA. I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three (3) days of being hired. Failure to submit such proof within the required time shall result in the immediate termination of employment. I represent and warrant that I have read and fully understand the forgoing and that I seek employment under these conditions.: *
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