Acmh Employment Application Form is an important document that must be filled out by all employees of the company. The form is used to collect personal and employment information from employees, as well as to track their progress throughout their tenure at Acmh. It is important that all information on the form is accurate and up-to-date, in order to ensure a smooth employment process. Properly completing this form will provide your new employer with all the necessary information they need to get you started on your new job. You can find a copy of the Acmh Employment Application Form online, or you can request one from your Human Resources department. Thank you for taking the time to complete this form!
Question | Answer |
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Form Name | Acmh Employment Application Form |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | you acmh orm, human acmh application, acmh application, human acmh orm |
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Human Resources Department |
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One Nolte Drive |
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Kittanning, PA 16201 |
EMPLOYMENT APPLICATION |
DATE: |
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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
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First Name |
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Middle Name |
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Prior Name(s) |
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Street Address |
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Social Security Number |
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Telephone Number |
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Alternate Telephone Number |
Are you legally eligible |
for work in the U.S.? |
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n yes |
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n no |
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Are you 18 years of age or older? |
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Have you ever been charged/convicted |
of a crime? |
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n yes |
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n no |
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n yes n no |
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A past conviction does not necessarily prevent you from being considered for employment, but will only be considered in relation |
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to specific job requirements. |
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POSITION DESIRED |
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Position Applying For |
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Nursing Specialties - Area of Interest |
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Desired Schedule (please √ each box that applies) |
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1st choice: |
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1st choice: |
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2nd choice: |
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2nd choice: |
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n |
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n Casual |
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Previously employed at ACMH? |
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n yes n no |
Dates: |
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n Temporary |
n Day |
n Afternoon |
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Date Available for Employment? |
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n Nights |
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n Weekends |
n Holidays |
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PROFESSIONAL LICENSES/CERTIFICATIONS |
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Type |
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State |
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Number |
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Expiration Date |
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Type |
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State |
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Number |
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Expiration Date |
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EDUCATION |
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Name & Address |
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# of Years |
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Major or Specialty |
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Dip./Degree |
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High School |
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College |
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Trade/Business |
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Other |
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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 |
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Entered |
Discharged |
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Are you aware of any reason you cannot perform the essential functions of the job(s) you are applying for, with or without |
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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 |
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 |
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City |
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State |
Zip Code |
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Position Held |
Employment Dates: |
Salary |
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Reason for Leaving |
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From |
To |
Start |
End |
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Most Recent Supervisor (include title) |
Telephone Number |
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May we contact for a reference? |
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n yes |
n no |
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Duties: |
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Company Name |
Street Address |
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City |
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State |
Zip Code |
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Position Held |
Employment Dates: |
Salary |
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Reason for Leaving |
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From |
To |
Start |
End |
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Most Recent Supervisor (include title) |
Telephone Number |
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May we contact for a reference? |
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n yes |
n no |
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Duties: |
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Company Name |
Street Address |
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City |
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State |
Zip Code |
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Position Held |
Employment Dates: |
Salary |
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Reason for Leaving |
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From |
To |
Start |
End |
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Most Recent Supervisor (include title) |
Telephone Number |
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May we contact for a reference? |
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n yes |
n no |
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Duties: |
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Company Name |
Street Address |
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City |
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State |
Zip Code |
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Position Held |
Employment Dates: |
Salary |
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Reason for Leaving |
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From |
To |
Start |
End |
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Most Recent Supervisor (include title) |
Telephone Number |
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May we contact for a reference? |
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n yes |
n no |
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Duties: |
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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 |
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