Employment Application | Glen Rose Medical Center

*Required Fields
*Cover Letter (Optional):*
PERSONAL INFORMATION
*First Name:
*Last Name:
Middle Initial:
Maiden Name:
*Present Address:
*City:
State:
*Zip Code:
*Phone Number:	( i.e. ### - ### - ####)
*Social Security Number:	( i.e. ### - ## - ####)
*Email Address:

GENERAL INFORMATION

Are you a U.S. Citizen? Yes No

If No, are you legally allowed to work in the U.S.? Yes No

If Yes, how long?

If employment is offered, can you submit a birth certificate, social security card, certificate of U.S. citizenship, or verification of your legal right to work in the U.S.? Yes No

If employment is offered, can you produce a personal identification such as a U.S. passport, a driver's license, or photographic identification card issued by the State? Yes No

What date are you available for employment?

Have you ever applied for a position with Glen Rose Medical Center? Yes No

Location of Previous Application?

Date of Previous Application?

EDUCATION
	Name of School	Address of School	Degree(s)	Date Attended
High School
College
Graduate School
Other

WORK PREFERENCES

What type of employment do you want? Full-time Part-time Summer

Will you work shifts? Yes No

For what type of position are you applying?

License type: (if applicable)

What is your minimum salary requirement?

EMPLOYMENT HISTORY (List below current and previous employers, starting with current or latest employer first)
Date (mm/yy)	Employer Name, Address & Phone	Salary	Position	Reason for Leaving
to
to
to
to

As an applicant for employment, I understand the following:

All information is subject to verification.
Any misrepresentation or falsification of information requested here will be cause for rejection of this application or for subsequent discipline up to and including my dismissal from employment.
If my application for employment is accepted, the effective date of my employment shall be the time I actually begin to work. If I am employed, I agree to comply with and be bound by the safety and health rules and regulations of Glen Rose Medical Center.
My employment is not guaranteed for any term, and my employment may be terminated by the company or myself for any reason.
No management official is authorized to make any oral assurance or promise of continued employment.
I authorize a thorough investigation of my past employment and activities, agree to cooperate in such investigation, and release from all liability or responsibility all persons and corporations requesting or supplying such information.
I agree to submit to any lawful drug testing that may be required as a condition of employment and understand that refusal to submit to such testing during the course of my employment may result in disciplinary action, up to and including discharge.
I understand that according to federal law all individuals who are hired must, as a condition of employment, produce certain documentation to verify their identity and U.S. citizen status, or, if aliens, their legal authorization to work in the U.S. Therefore, I realize that any offer of employment would be contingent upon my ability to produce the required documentation within the time period required by law.

This Company will not discriminate against any employee or applicant for employment because of age, religion, sex, race, color, national origin, disability, non-job-related handicap, or because they are a disabled veteran or Vietnam era veteran. Answers to application questions will be utilized for applicable, job-related information only.