Delta Regional Medical Center

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Job Application

Application for Employment

This application is intended to provide information evaluating your suitability for employment and is not intended to be a contract for employment of any type. It is very important for you to read each question carefully and give an honest and complete answer. Qualified applicants receive consideration for employment without unlawful discrimination because of sex, religion, race, color, national origin, age, disability or other classification protected by law. Applicants will remain active for three months.

* - Required Information

*Position(s) Applying for:

Click Here for a list of current jobs.

Contact Information:

*Name:

First

Last

*Address:

*City:

*State:

*Zip:

*Email:

*Phone:

How did you learn about us?

	Walk-in
	Friend
	Relative
	Jobline
	DRMC Website
	WIN Job Service
	Career / Job Fair:
	Advertisement: (Please State Name of Publication)
	Employee: Reffered by:
	Other:

If related to any employee of DRMC. Please state name and department:

If you have been employed under another name, please list it here:

Are you under 18 years of age?

Yes

Are you currently employed?

Yes

May we contact your present employer?

Yes

Do you have legal rights to work in this country?
(Proof of legal rights to work in this country will be required upon employment)

Yes

Have you been employed with us before?

Yes

Are you available to work:

Full-Time

Part-Time

PRN

Temporary

Are you available to work overtime if required?

Yes

How flexible are you in accepting varying scheduled hours?

Very Flexible
Somewhat Flexible
Need Set Schedule

Minimum Salary Desired: $

Have you ever been discharged from a job or forced to resign?
If "Yes" please explain:

Yes

Are you currently included as a provider of services by Medicare, Medicaid or any pother federal or state health care program?

Yes

Should an exclusion occur in the future, will you agree to notify Delta Regional Medical Center within 10 days of exclusion?

Yes

Have you ever been convicted of a crime or violation other than a minor traffic infraction?
If "Yes" please explain:

Yes

"Criminal convictions are not an absolute bar to employment, but will only be considered with respect to the specific requirements of the job for which you are applying."

Education

High School:
Graduate/GED?	Yes No

College:
Graduated?	Yes No
Year Graduated?
Major/Field(s) of Study:
Degree:

Major/Field(s) of Study:
Degree:

Techical, Business or Correspondence School:
Graduated?	Yes No
Year Graduated?
Major/Field(s) of Study:
Degree:

Major/Field(s) of Study:
Degree:

Describe any specialized training, apprenticeship and skills such as computer, office equipment, etc. :

License(s) and Certification(s):

Type of License(s)/Certification(s):
	Expiration: (mo/day/year)

Type of License(s)/Certification(s):
	Expiration: (mo/day/year)

Type of License(s)/Certification(s):
	Expiration: (mo/day/year)

References:

Give name, address and telephone number of three refernces that you have known for at least one year who are not related to you.

Reference 1:

Name:
Phone:
Years Acquainted:
Address:
City:
Business:

Reference 2:

Name:
Phone:
Years Acquainted:
Address:
City:
Business:

Reference 3:

Name:
Phone:
Years Acquainted:
Address:
City:
Business:

Employment Experience:

Please list all employment experience with the most recent employment first.

Employer 1 (most recent):

Name:
Phone 1:
Phone 2:
Address:
City:
Supervisor's Name:
Supervisor's Title:
Reason for Leaving:
Salary Received:	$ Hourly Weekly Monthly
Employed from:	to (month/year)
Duties and skills Performed:

Employer 2 (most recent):

Name:
Phone 1:
Phone 2:
Address:
City:
Supervisor's Name:
Supervisor's Title:
Reason for Leaving:
Salary Received:	$ Hourly Weekly Monthly
Employed from:	to (month/year)
Duties and skills Performed:

Employer 3 (most recent):

Name:
Phone 1:
Phone 2:
Address:
City:
Supervisor's Name:
Supervisor's Title:
Reason for Leaving:
Salary Received:	$ Hourly Weekly Monthly
Employed from:	to (month/year)
Duties and skills Performed:

Employer 4 (most recent):

Name:
Phone 1:
Phone 2:
Address:
City:
Supervisor's Name:
Supervisor's Title:
Reason for Leaving:
Salary Received:	$ Hourly Weekly Monthly
Employed from:	to (month/year)
Duties and skills Performed:

Do you expect any of the employers listed above to give you a poor reference?

Yes

Application Update:

List any job-related information not given on your previous application.

Upload Resume:

If you wish, you can upload your resume here in an acceptable format
(Word or PDF only.)

(Image file size cannot exceed 1MB in size.)

Applicant's Statement

I hereby agree that all of my statements and information are true, and I understand that any false statement or omissions are cause for termination. I agree to submit a drug/alcohol test and/or physical following any conditional offer of employment, and I grant permission to Delta Regional Medical Center to investigate any criminal history, education, prior employment history and references, and hereby release all persons or agencies from liability for any damage for issuing this information.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of "at will" nature, which means that I, the employee, may resign at any time, and the employer relationship may not be changed except in writing by the Chief Executive Officer or Chief Human Resources Officer.

I understand that this application is current for only three months. At the end of that time, if I do not hear from Delta Regional Medical Center and still wish to be considered for Employment, it will be necessary for me to update my application.

Yes, I agree to the above terms. No, I do not agree to the above terms.

Click here to review Addendum to Delta Regional Medical Center Application for Employment