POSITION YOU DESIRE:

HOW DID YOU HEAR ABOUT OUR JOB OPPORTUNITIES?

NAME:

Last Name   First Name Middle Name

ADDRESS:

Street Address       City    State     Zip

Telephone Number:

email Address:

Type of employment you want:  (check all that apply)   Full Time      Part Time     Temporary     Summer

Shift Desired: (check all that Apply)       Days     Evenings      Nights

Are you 18 Years of age or older ?    Select one Yes No

EDUCATION:

Name and Location of Schools Attended: (include highest grade, degree or certification completed):

    High School

    College or University

    Specialized Education

Have you ever been convicted by law of any violations (except minor traffic accidents)? Select Answer Yes No

Have you ever been employed at Montrose Memorial Hospital? Select Answer Yes No

                           If yes When?

If hired, can you furnish proof that you are eligible to work in the United States?   Select Answer Yes No

PROFESSIONAL LICENSES AND REGISTRATIONS

Your Colorado Professional, Vocational, Certification Number Expiration date

Was or has your license ever been revoked, suspended, voluntarily relinquished or have you ever been disciplined
by a licensing authority?  Select Answer Yes - explain below No Not Applicable

If answer was Yes to previous question, please explain:

Experience or License to operate specialized hospital equipment - Please List:

Please complete this section if applying for a Clerical Related Position
List any skills, that you have that apply to the position for which you are applying::

Prior Employment

List the names of employer, full and part time, in consecutive order, with present employer first.  Account for all periods of time including military service and any periods of unemployment.  If self employeed, give name of firm and supply business references.  Please give both month and year of employment.

Prior Employment 1

Name and Address of employer: Phone:

Dates of Employment:      Pay Rate:

Supervisor's Name and Title:

Reason for Leaving:

Your Title and Duties (briefly summarize):

Prior Employment 2

Name and Address of employer: Phone:

Dates of Employment:      Pay Rate:

Supervisor's Name and Title:

Reason for Leaving:

Your Title and Duties (briefly summarize):

Prior Employment 3

Name and Address of employer: Phone:

Dates of Employment:      Pay Rate:

Supervisor's Name and Title:

Reason for Leaving:

Your Title and Duties (briefly summarize):

I hereby authorize Montrose Memorial Hospital to contact all employers listed, including my present employer  Please Select One Yes, I give authorization No, I do not give Authorization Please see my notes on authorization

          Notes on authorization to contact employers:
                   

Please read carefully before submitting:

*    I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.
*    I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.
*    I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre-employment or post-offer drug screen as a condition of employment, if required.
*    I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical agility examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying.
*    I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS BY MANAGEMENT, OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT NO GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. ONLY THE CEO OF THE MONTROSE MEMORIAL HOSPITAL HAS THE AUTHORITY TO ENTER INTO AN AGREEMENT OF EMPLOYMENT FOR ANY SPECIFIED PERIOD AND SUCH AGREEMENT MUST BE IN WRITING, SIGNED BY THE CEO AND THE EMPLOYEE. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT REASON AND WITH OR WITHOUT NOTICE.

I have read and understand the statements above.  By submitting I consent to these statements.

When Completed Please Submit !