Laughlin Memorial Hospital

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NAME & LOCATION

Last Name

First Name

Middle Name

Current Address (Street & Number)

Home Phone#

Other Phone#

City

State

Zip code

Social Security No.

EMPLOYMENT DESIRED

Position Desired (First Choice)

Experience?

Yes No

Have You Worked with Us Before?

Yes No

(If Yes, Date Left)

Have You Worked with Us Before Under another Name?

Yes No

If Yes, State Name

Position Desired (Second Choice)

Experience?

Yes No

Will You Accept Part Time Work?

Yes No

Will You Accept Temporary Work?

Yes No

Shift or Hours You Can Work

1st 2nd 3rd

Other Comments

EDUCATION

Date Avail. To Start Work

Do You Realize that it may be necessary for you to work weekends, holidays or rotation shift

Yes No

Date Of Birth If Under 18

Highest Grade Completed

Name of School	Address of School	Major Courses
High School	.	.

College	.	.

Technical or Trade	.	.

Other	.	.

EXPERIENCE

Give a complete record of all employment and reasons for periods of unemployment during the past ten years. Start with the most recent employment.

Last Employment First

____________________________________________________________________Last Employer

FROM

Employer

Salary

May We Check This Reference?

Yes No

Street Address

Phone

Position

City

State

Zip code

Supervisor

Reason For Leaving

__________________________________________________________________Second Employer

FROM

Employer

Salary

May We Check This Reference?

Yes No

Street Address

Phone

Position

City

State

Zip code

Supervisor

Reason For Leaving

_____________________________________________________________________Third Employer

FROM

Employer

Salary

May We Check This Reference?

Yes No

Street Address

Phone

Position

City

State

Zip code

Supervisor

Reason For Leaving

NURSING APPLICANTS ONLY

Please Check area in which you have experience or special interest:

ICU	PR	Med/Surg	Prior Nursing Home Experience
ICN	OB	Pediatrics	Other - Please specify

Are You Registered/Licensed in Tenn.?

Yes No

Registration No.

Expiration Date:

If not have You applied?

Yes No

THIS SECTION IS FOR TECHNICIANS AND TECHNOLOGISTS PROFESSIONALS ONLY

Please list current professional registrations, licenses and/or certifications Certifying or Licensing Association	Number	Expiration Date

CLERICAL AND SECRETARIAL APPLICANTS

Typing Skills Yes No	Speed WPM
Transcription Exp. Yes No	Speed WPM
Office Machines Used:

SERVICE IN US ARMED FORCES

Have You ever served in the US Armed Forces? Yes No	If Yes, Date Active Duty Started 19
Which Service?

CITIZENSHIP

ARE YOU EITHER A UNITED STATES CITIZEN OR AN ALIEN WHO HAS THE LEGAL RIGHT TO WORK IN THE JOB FOR WHICH YOU ARE APPLYING?	Yes No
______________________________________________________________________________
PURSUANT TO THE IMMIGRATION REFORM AND CONTROL ACT OF 1986, ALL APPLICANTS, UPON BEING MADE AN OFFER OF EMPLOYMENT, MUST PRODUCE DOCUMENTS, WHICH ARE SPECIFIED BY THE FEDERAL GOVERNMENT, ESTABLISHING THEIR IDENTITY AND AUTHORIZATION FOR EMPLOYMENT IN THE UNITED STATES. THESE DOCUMENTS MUST BE PRODUCED NO LATER THEN SEVENTY-TWO (72) HOURS AFTER COMMENCEMENT OF EMPLOYMENT. YOU WILL ALSO BE REQUIRED TO SIGN FORM I-9 (ISSUED BY THE FEDERAL GOVERNMENT. VERIFYING UNDER OATH, YOUR EMPLOYMENT AUTHORIZATION).

PERSONAL

Have you ever been convicted of a felony?

Yes No

If Yes, Nature

(Any affirmative answer will not automatically disqualify you from being considered for employment)

Have you ever been discharged from a job?

Yes No

If Yes, Explain

Have you any relatives employed at our facility?

Yes No

If Yes, give names

Have you any friends employed at our facility?

Yes No

If Yes, give names

Do you have any handicaps or health conditions which should be taken into account in determining job placement?

Yes No

If Yes, please explain

Do you have any commitments to another employer that might affect you employment with us?

Yes No

Do you understand that due to the nature of the services we provide, an exceptional record of attendance , promptness, and dependability is required of all employees?

Yes No

Do you understand that employment is contingent upon passing a Health Screening examination which includes a pre-employment drug screen and satisfactory education, prior employment, and reference verification?

Yes No

Do you understand that the first 90-days of employment will be considered as a period of introduction and/or adaptation - and that employment may be terminated during this period by either the employee and or the employer without prejudice and with no eligibility for accrued benefits or severance pay?	Yes No
I understand that no monetary increase will be given after completing my 90-day Introductory Trial Period.

Living Will