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Employment Application

We appreciate your interest in our organization and assure you we are sincerely interested in your qualifications. A clear understanding of your background and work history will aid us in placing you in the position that best meets your qualifications and may assist us in future upgrading. This facility is an Equal Opportunity Employer. Employment, educational opportunities and promotions in all job classifications are without regard to race, creed, sex, age, national origin, religion, disabilities or military status.

Position Applying For:*
Name*
First Middle Last
Have you ever been employed or attended school under another name?*
- Yes
- No
Please indicate former name.*
Email*
Phone*
Address*
Street Address City State ZIP Code
Are you at least 18 years of age?*
- Yes
- No
What is your age?*
Date Available for Employment*
Minimum Salary Desired
Hours desired?
- Full-Time
- Part-Time
Shifts you are available to work?
- Days
- Evenings
- Nights
- Weekends
- Holidays
Have you ever been employed at Winner Regional Healthcare Center?*
- Yes
- No
When and in what capacity?*
Who referred you to our organization?*
- Newspaper
- Internet
- Our Website
- Employee
- School
- On My Own
- Other
Please specify reference:*
Please specify employee name:*
Upload Resume and/or Cover Letter
Drop files here or

Accepted file types: pdf.
General Information
Have you ever been convicted of, found guilty of, or pleaded guilty to, a felony of any kind?*
- Yes
- No
Please explain.*
Have you ever been discharged or forced to resign from any position?*
- Yes
- No
Please explain.*
Have you ever had your privilege to practice revoked or reduced or otherwise restricted?*
- Yes
- No
- N/A
Please explain.*
Has your license or certification ever been denied, revoked, suspended, stipulated, placed on probation or otherwise subject to any type of disciplinary action?*
- Yes
- No
- N/A
Please explain.*
Educational History
Check all education levels you have completed or are currently working on?*
- High School
- Professional/Trade School
- Associate or Bachelor Degree
- Graduate Degree
High School Name
High School Address
City State
High school course of study?
Are you currently enrolled in high school?
- Yes
- No
Did you graduate high school?
- Yes
- No
Highest High School Grade Completed
- 8
- 9
- 10
- 11
- 12
- GED
College Name
College Address
City State
College course of study?
Are you currently enrolled in college?
- Yes
- No
Did you graduate college?
- Yes
- No
College Grade Completed
- Freshman
- Sophomore
- Junior
- Senior
Graduate School Name
Graduate School Address
City State
Graduate school course of study?
Are you currently enrolled in graduate school?
- Yes
- No
Did you complete graduate school?
- Yes
- No
Graduate school degree(s)?
Professional/Trade School Name
Professional/Trade School Address
City State
Professional/Trade school course of study?
Did you complete professional/trade school?
- Yes
- No
Professional/Trade school degree(s)/certificate(s)?
Have you served in the military?
- Yes
- No
Are you currently active?*
- Yes
- No
Branch of Military
Starting Date of Service
Ending Date of Service
Highest Rank Achieved
Duties
Please list special skills and/or qualifications which may be relevant to the position you are applying for:
Professional Licensure/Certification/Registration
Do you have a Professional Licensure/Certification/Registration?
- Yes
- No
Type*
Number*
State*
State
Expiration Date*
Do you have a second Professional Licensure/Certification/Registration?*
- Yes
- No
Second Type*
Number (2)*
State (2)*
State
Expiration Date (2)*
Employment History
Please include four employers if available.
Are you currently employed?
- Yes
- No
May we contact your present employer?
- Yes
- No
Company Name
Position/Title
Address
Street Address City State ZIP Code
Start Date
End Date
List of Duties
Reason for Leaving
Supervisor Name
First Last
Supervisor Phone
Hourly Rate/Salary
Second Employer
Company Name (2)
Position/Title (2)
Address (2)
Street Address City State ZIP Code
Start Date (2)
End Date (2)
List of Duties (2)
Reason for Leaving (2)
Supervisor Name (2)
First Last
Supervisor Phone (2)
Hourly Rate/Salary (2)
Do you have a third employer to list?
- Yes
- No
Third Employer
Company Name (3)
Position/Title (3)
Address (3)
Street Address City State ZIP Code
Start Date (3)
End Date (3)
List of Duties (3)
Reason for Leaving (3)
Supervisor Name (3)
First Last
Supervisor Phone (3)
Hourly Rate/Salary (3)
Do you have a fourth employer to list?
- Yes
- No
Fourth Employer
Company Name (4)
Position/Title (4)
Address (4)
Street Address City State ZIP Code
Start Date (4)
End Date (4)
List of Duties (4)
Reason for Leaving (4)
Supervisor Name (4)
First Last
Supervisor Phone (4)
Hourly Rate/Salary (4)
References
School or personal references we may contact. (Do not list relatives.)
Name*
First Last
Title/Occupation
Company Name
Address
Street Address City State ZIP Code
Phone*
Second Reference
School or personal references we may contact. (Do not list relatives.)
Name (2)*
First Last
Title/Occupation (2)
Company Name (2)
Address (2)
Street Address City State ZIP Code
Phone (2)*
Third Reference
School or personal references we may contact. (Do not list relatives.)
Name (3)*
First Last
Title/Occupation (3)
Company Name (3)
Address (3)
Street Address City State ZIP Code
Phone (3)*
Voluntary Affirmative Action Information
Sex
- Male
- Female
Ethnicity
- Caucasian
- Black or African American
- Hispanic or Latino
- Native Hawaiian or Pacific Islander
- American Indian/Alaskan Native
- Asian
- Two or more races
Please mark the appropriate veteran status:
- Active Military
- Disabled Veteran
- Other Protected Veteran
- Armed Forces Service Medal Veteran
- Recently Separated Veteran
Applicant’s Statement
I hereby give Winner Regional Healthcare Center the right to investigate my past employment, education and activities. I release from all liability all persons, schools, companies and corporations who supply such information. I release Winner Regional Healthcare Center against any liability that might result from such investigation. I understand that any false answer or statements or implications I might make in this application or in any other required document shall be considered sufficient cause to deny employment or for discharge if already employed.

I also understand that nothing contained in this application or in the granting of an interview is intended to create an employment contract between Winner Regional Healthcare Center for employment or for any benefit. I have received no promise regarding employment and I understand that no such promise or guarantee is binding on Winner Regional Healthcare Center unless an employment relationship is established. I understand that I have the right to terminate my employment at any time and that Winner Regional Healthcare Center has the same discharge rights.

I understand that if offered a position with Winner Regional Healthcare Center, I will be required to submit to a pre-employment health assessment, drug screening and background check as a condition of employment. I understand unsatisfactory results from, refusal to cooperate with, or any attempt to affect the results of these pre-employment tests and checks will result in withdrawal of any employment offer or termination of employment if already employed. Also, if hired at Winner Regional Healthcare Center, prior to my first day of work, I will be required to verify that I am either a U.S. citizen or a legal resident foreign national.
For the above statement:*
- I Accept, Submit My Application
You must accept the terms of the agreement to submit your application. If you do not click Accept, your application will not be saved or submitted.
Comments
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