Application

First Name

Last Name

Address *Please fill the required field.

Phone *Please fill the required field.

Email *Please fill the required field.

Driver's License Number

Type of Employment Desired

Full Time

Part Time

Temporary

Date you will be available to start work

Are you able to meet the attendance requirements?

Yes

No

Do you have any objection to working overtime if necessary?

Yes

No

Have you ever been previously employed by our organization?

Yes

No

Can you submit proof of legal employment authorization and identity?

Yes

No

Do you have a medical condition that will affect your work performance?

Yes

No

If yes, please explain.

Have you ever been convicted of a felony?

Yes

No

If yes, please explain.

How were you referred to us?

If you are under 18, can you furnish a work permit if it is required?

Yes

No

Previous Employer #1

Address

Phone

Immediate Supervisor and Title

Dates Employed

Last Salary

Job Summary

Previous Employer #2

Address

Phone

Immediate Supervisor and Title

Dates Employed

Last Salary

Job Summary

Other Skills and Qualifications

High School Attended

College Attended

Technical Training

Other

Reference #1 - Include Name, Telephone Number, and Years Known (no relatives or employers)

Reference #2 - Include Name, Telephone Number, and Years Known (no relatives or employers)

Reference #3 - Include Name, Telephone Number, and Years Known (no relatives or employers)

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.

Yes

No

Please fill the required field.

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Contact Us

510 East Main Street
Antlers, OK 74523

Call Us
580.298.3341

Billing/Payment Information:
Pushmataha Hospital - Business Office
PO Box 518
Antlers, OK 74523-0518
Phone: 580.298.3341 x405

Opening Time
24/7/365

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Contact Us

510 East Main Street Antlers, OK 74523

Call Us580.298.3341

Billing/Payment Information: Pushmataha Hospital - Business OfficePO Box 518Antlers, OK 74523-0518Phone: 580.298.3341 x405

Opening Time24/7/365