Acmh Employment Application Form PDF Details

The Acmh Employment Application form is a comprehensive tool used by the Armstrong County Memorial Hospital's Human Resources Department to streamline the hiring process. Located at One Nolte Drive, Kittanning, PA, ACMH prides itself on being an equal opportunity employer, staunchly adhering to a non-discrimination policy based on race, creed, color, sex, age, disability, religion, or national origin. This form covers an array of essential topics, from personal information, legal work eligibility, and age verification to specific job-related inquiries such as past convictions, desired position, and scheduling preferences. It also delves into applicants' professional licenses or certifications, educational background, and distinctive skills or qualifications pertinent to potential employment. Another critical section requests information on military service, ability to perform job functions with or without reasonable accommodations, and professional references who can attest to the applicant's work capabilities. Employment history is scrutinized, with space provided for detailing past roles, responsibilities, and reasons for leaving, encouraging a current resume to supplement this data. A concluding agreement and release segment requires applicants to authorize ACMH to verify the provided information and understand the implications of any false statements. This form is not only a gateway for prospective employees considering a career at ACMH but also a testament to the hospital's commitment to a thorough and equitable selection process.

QuestionAnswer
Form NameAcmh Employment Application Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesyou acmh orm, human acmh application, acmh application, human acmh orm

Form Preview Example

 

 

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