Acmh Employment Application Form – Fill Out and Use This PDF

		Human Resources Department
		One Nolte Drive
		Kittanning, PA 16201	EMPLOYMENT APPLICATION
DATE:	/	/

As an equal opportunity employer, Armstrong County Memorial Hospital (ACMH) does not discriminate in hiring or terms and conditions of employment because of an individual’s race, creed, color, sex, age, disability, religion or national origin.

PERSONAL INFORMATION

Last Name

First Name

Middle Name

Prior Name(s)

Street Address

City

State

Zip Code

Social Security Number

Telephone Number

Alternate Telephone Number

Are you legally eligible

for work in the U.S.?

n yes

n no

Are you 18 years of age or older?

Have you ever been charged/convicted

of a crime?

n yes

n no

n yes n no

A past conviction does not necessarily prevent you from being considered for employment, but will only be considered in relation

to specific job requirements.

POSITION DESIRED

Position Applying For

Nursing Specialties - Area of Interest

Desired Schedule (please √ each box that applies)

1st choice:

1st choice:

2nd choice:

2nd choice:

n Full-time

n Part-time

n Casual

Previously employed at ACMH?

n yes n no

Dates:

n Temporary

n Day

n Afternoon

Date Available for Employment?

n Nights

n Weekends

n Holidays

PROFESSIONAL LICENSES/CERTIFICATIONS

Type

State

Number

Expiration Date

Type

State

Number

Expiration Date

EDUCATION

Name & Address

# of Years

Major or Specialty

Dip./Degree

High School

College

Trade/Business

Other

SPECIAL SKILLS AND QUALIFICATIONS

Summarize special skills and qualifications acquired from employment or other experiences that may qualify you for employment:

MISCELLANEOUS INFORMATION

Have you ever served in the U.S. Armed Forces?	n yes	n no	Branch	Date	Date
				Entered	Discharged

Are you aware of any reason you cannot perform the essential functions of the job(s) you are applying for, with or without
reasonable accommodations?	n yes	n no

PROFESSIONAL REFERENCES (List three (3) persons who can evaluate your abilities within a work environment.)

Name	Company and Title	Telephone
Name	Company and Title	Telephone
Name	Company and Title	Telephone

EMP-2 (6/08)

List most recent employer first (Additional employment should be listed on an attached sheet.) In addition to the information provided below, please attach a current resume if available.

EMPLOYMENT HISTORY

Company Name	Street Address		City		State	Zip Code
Position Held	Employment Dates:		Salary		Reason for Leaving
	From	To	Start	End
Most Recent Supervisor (include title)	Telephone Number		May we contact for a reference?
			n yes	n no
Duties:
Company Name	Street Address		City		State	Zip Code
Position Held	Employment Dates:		Salary		Reason for Leaving
	From	To	Start	End
Most Recent Supervisor (include title)	Telephone Number		May we contact for a reference?
			n yes	n no
Duties:
Company Name	Street Address		City		State	Zip Code
Position Held	Employment Dates:		Salary		Reason for Leaving
	From	To	Start	End
Most Recent Supervisor (include title)	Telephone Number		May we contact for a reference?
			n yes	n no
Duties:
Company Name	Street Address		City		State	Zip Code
Position Held	Employment Dates:		Salary		Reason for Leaving
	From	To	Start	End
Most Recent Supervisor (include title)	Telephone Number		May we contact for a reference?
			n yes	n no
Duties:

AGREEMENT AND RELEASE

My signature below indicates that I have read, I understand and I agree to the following:

I hereby authorize Armstrong County Memorial Hospital (ACMH) to make whatever inquiries and investigations it deems necessary of any person or organization to verify any of the information given in this application and accompanying resume, if any. I understand the results of such inquiries will be used to further determine my qualifications and abilities for the job(s) for which I have applied and that all information obtained by ACMH will be used in making a hiring decision. I also authorize any school official and any other person or organization having control of any information pertaining to me, or to my application for employment, to furnish the information to ACMH. I hereby release and exonerate any such school official or any other person or organization from any liability whatsoever in relation to compliance with a request for such information from ACMH. I have read and completed this application form and fully understand all the questions and answers contained therein. I certify that the information contained in this application and accompanying resume, if any, to the best of my knowledge, is correct. I fully understand and agree that any false statement, misrepresentation, or omission from this application and accompanying resume, if any, will fully justify and, at the option of ACMH, may cause my dismissal from employment at ACMH, regardless of the time when any statement may be found to be false, misrepresented, or omitted. I understand that as a condition of employment, I must be available to work any shift as required.

Signature

Date