Employment Application Form

Course of Study
Years Attended
Year Graduated
Degree Obtained

Employment here is for an indefinite term; it is terminable at any time by either the employee or the employer. No employee or representative of the employer except the CEO (Chief Executive Officer) has the power to commit the employer otherwise and then only if such a commitment is in a signed written document. Nothing in our Employee Reference Guide, policy or practice, shall be deemed to establish the employment of any person on a basis other than terminable at the will of either the employee or the Hospital. No verbal statements otherwise shall be binding with the employer or the Hospital or both.

Employer Addresses
Dates Month & Year
Type of Work
Supervisor name and Telephone Number
Reason for leaving

I hereby give permission to contact any and all former employers and associates they find necessary in determining my eligibility for employment except as noted above. I certify that the answers to the above questions are correct and that any misstatement of fact shall be sufficient cause for dismissal.

I have agreed to the conditions of employment at and agree to work as stated:

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