Instructions: Complete all requested information. Any applicant who provides unrequested information will be automatically rejected from employment consideration. Myrtue Medical Center is an equal opportunity employer and will not discriminate, or tolerate discrimination, against any employee or applicant in any manner prohibited by law. Pre-employment health assessment, drug screen and background checks are required. Myrtue Medical Center is tobacco-free.

Position(s) Applied For:

Date of Application:

Date Available:

Salary Desired:

Are you currently employed?

Yes

Available to Work:

Full Time

Part-Time

On-Call

Temporary

Last Name First Name MI

Address City State Zip

Telephone No.

Educational Background

Education	Name and Location of School	Course of Study	Did you graduate?	Degree or Diploma
High School
College
Other (specify)

Employment History

Present and former employers listed will be contacted as references if you are a finalist for a position. If you do not have a history of at least three employers, please provide the names, addresses, and telephone numbers of other references who are not related to you.

Employer
Address
Telephone Number(s)
Job Title/Position
Name of Supervisor
Reason for Leaving
Account for Period Between Jobs

Dates Employed
From	To
Hourly Rate/Salary
Starting	Final

Brief Description

Employer
Address
Telephone Number(s)
Job Title/Position
Name of Supervisor
Reason for Leaving
Account for Period Between Jobs

Dates Employed
From	To
Hourly Rate/Salary
Starting	Final

Brief Description

Employer
Address
Telephone Number(s)
Job Title/Position
Name of Supervisor
Reason for Leaving
Account for Period Between Jobs

Dates Employed
From	To
Hourly Rate/Salary
Starting	Final

Brief Description

Employer
Address
Telephone Number(s)
Job Title/Position
Name of Supervisor
Reason for Leaving
Account for Period Between Jobs

Dates Employed
From	To
Hourly Rate/Salary
Starting	Final

Brief Description

By submitting below, I certify that the answers and information set out in this application for employment are true, accurate, and complete to the best of my knowledge. I acknowledge that if any answer or information is not true, accurate, or complete, I may not be hired, or if hired, I may be discharged. I authorize Myrtue Medical Center to investigate all statements contained in this application for employment and to investigate my character and qualifications. I authorize my prior employers, references, and others with information regarding my work or educational history, or my character, to provide Myrtue Medical Center with all requested information and references, and to cooperate fully with the investigation of my character and qualifications. I further release Myrtue Medical Center, and any person or organization providing information to Myrtue Medical Center regarding my work or educational history, character or qualifications from any liability for soliciting and securing or for providing such information.

I understand that this application is not a contract of employment, and I acknowledge that no oral representations have been made as such. I further understand that I will only be considered for employment opportunities Myrtue Medical Center for 90 days from the date of this application. If hired, I understand that my employment relationship with Myrtue Medical Center is terminable at-will, with or without cause, by either myself or Myrtue Medical Center.

In compliance with the Americans with Disabilities Act, I understand that if hired, I will be required to complete an employee health screening medical history statement. This statement is required of all employees of Myrtue Medical Center. Any medical information acquired will be preserved as confidential and kept in a file separate from my personnel file. If hired, I understand that the job offer I receive will be “conditioned” upon my being able to perform the essential job functions of the position with or without reasonable accommodation.