Secure Online Employment Application
SJMH logs all server requests to this page.
Date
SSN Last Name First Name Middle
Maiden Address Address 2 City State Zip Code Email Telephone Number
In Case of Emergency, Notify:
Name
Address
Telephone
Clinical Area Preferred 1 2 3 Availability: (Please mark any that apply) Day Shift Evening Shift Night Shift Full-Time Part-Time PRN Other
If Part-time/PRN, what hours can you work?
Can you work weekends?
Are you eligible to work in the US? Yes No
Are you under 18 years of age? Yes No
Have you ever been employed here? Yes No
If So, under what name?
Position:
Dates of Employment:
Reason For Leaving:
Please list any relatives currently working for SJMH and their relationship to you.
If you are currently employed, why do you wish to change jobs?
What prompted you to apply here and how were you referred?
Have you ever been convicted of a felony, or a crime involving dishonesty, abuse or neglect?
Yes No
If So, please explain
Have you ever been excluded from participating in federal health care programs, including Medicare and Medicaid? Yes No ( A query of the US Department of Health & Human Services Office of Inspector General's List of Excluded Individuals/entitles will be conducted as a condition of employment.) A query will be conducted for all Certified Nursing Assistants of the West Virginia Nurses Aid Registry.
Membership in professional organizations:
Have you ever been terminated from employment? If so, please explain.
Registration Number, if licensed:
State(s) licensed:
Have you ever had any restrictions of disciplinary action on your license? Yes No
Special Abilities or Skills:
Typing w/p/m: Shorthand w/p/m:
Business Machines Operated:
Education
Name/Address of High School:
Course of Study:
Degree or Diploma:
Name/Address of College(s):
Name/Address of Other:
Former Employers and Work Experience
Have you ever served in the military service? Yes No
(Include all previous work history/Military Service, Beginning with the most recent job first. Add additional sheet(s) if necessary)
Name:
Address:
Telephone:
Name of Supervisor:
Position Held:
Major Duties, Responsibilities:
Salary:
Reason for Leaving:
Please note those employers above that may recognize you as a different name. Please include the name used during employment.
Personal References
(Not former Employers or Relatives)
Mailing Address:
Telephone (Day & Evening):
Occupation:
Additional Information
I hereby certify that the above information is true and complete. I understand that any false answers or significant omissions may be grounds for denial of emplyment or discharge if discovered after my employment. The companies, schools and persons listed may be contacted and give information reguarding me. I hereby release them and SJMH from all liability of information disclosed in the course of the employment process.
I understand that any offer of employment is not an offer of permanent, i.e., lifetime employment and this application, any other employment papers or informational documents given to me by SJMH do not constitute a contract of employment. I agree to be examined by a physician designated by SJMH if I am given and accept an offer from SJMH, and understand that active employment is constingent on the results of that examination and drug test.
AUTHORIZATION: I voluntarily give Stonewall Jackson Memorial Hospital permission to make a thorough investigation of my background regarding education and/or employment and all other facts within my application for employment. I release from liability all persons, places of business and municipalities supplying such information. I understand the information provided will become the confidential property of Stonewall Jackson Memorial Hospital.
* Due to electronic security regulations this emailed job application may be accepted as signed acknowledgement by individual.
Applicant Name:
