MDH Application for Employment

Full Name: e-mail

Address

City   State    Zip    Telephone

Social Security Number    Desired Hourly rate of Pay 

Position Desired     Hours Desired Full-Time Part-Time PRN Temporary

When are you available to start?  

Do you have any special education or training skills?

Educational History

Graduate School  Please list Name and Location of School, Course of Study, Dates Attended, and Degree Awarded.

College  Please list Name and Location of School, Course of Study, Dates Attended, Number of years Completed, and Degree Awarded if applicable.

High School  Please list Name and Location of School, Dates Attended, Number of years Completed, and if awarded Diploma or GED.

Elementary Education  Please list Name and Location of School, Dates Attended, and Number of years Completed.

Are you a member of any Professional Organizations?  Yes  No 

If Yes, Please List 

Employment History

Please give accurate and complete work history for all employment for the last 10 years starting with most recent employer.

Company Name     Telephone

Address    Employment Dates

Name of Supervisor    Salary Hourly Weekly Monthly Annual

Your Job Title   Describe Work 

Reason for Leaving

Company Name     Telephone

Address    Employment Dates

Name of Supervisor    Salary Hourly Weekly Monthly Annual

Your Job Title   Describe Work 

Reason for Leaving

Company Name     Telephone

Address    Employment Dates

Name of Supervisor    Salary Hourly Weekly Monthly Annual

Your Job Title   Describe Work 

Reason for Leaving

Company Name     Telephone

Address    Employment Dates

Name of Supervisor    Salary Hourly Weekly Monthly Annual

Your Job Title   Describe Work 

Reason for Leaving

Please list any employers above we should not contact and provide reason as to why.

Did you serve as member of the Armed Forces?  Yes  No  If yes what Branch? Army NONE Navy Air-Force Marines National Guard Reserves

List any special training you received

Personal References

Please list three Personal References and provide contact information.

By Submitting this application, you are hereby attesting that the information is true, correct and complete to the best of your knowledge.  If you employ me, any misstatement or omission of fact on this application may result in my termination.  I also understand that acceptance of an offer of employment creates no obligation upon you, Meade District Hospital, to continue to employ me in the future.

Indicate you have read and agree with the above information by entering your initials here here.