Employment Application | Haskell Memorial Hospital

Position you are applying for

How did you hear about us?

If other, please specify

Best time to contact you at home is:

Morning (9:00am to noon) Afternoon (Noon to 5:00pm) Evening (5:00pm to 7:00pm)

If you are under 18 years of age, can you provide required proof of your eligibility to work?

Yes No

Have you ever filed an application with us before?

Yes No

If yes, select date:

Have you ever been employed with us before?

Yes No

If yes, select date:

Do any of your friends or relatives, other than spouse, work here?

Yes No

Are you currently employed?

Yes No

May we contact your present employer?

Yes No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?
Proof of citizenship or immigration status will be required upon employment.

Yes No

Date available to start working

What is your desired salary?

Are you available to work:

Full-time Part-time Temporary

For full-time indicate shift(s):

Shift 1 Shift 2 Shift 3

For part-time indicate availability:

Morning Afternoon Evening

For temporary list dates available:

Are you currently on "lay-off" status and subject to recall?

Yes No

Can you travel if a job requires it?

Yes No

Other Qualifications

Specialized Skills

Can you perform the essential functions of the job for which you are applying, either with or without a reasonable accommodation?
ONLY ANSWER IF YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Yes No

I certify that answers given herein are true and complete. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Click here to certify

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NOTICE TO PATIENTS

This practice serves all patients regardless of inability to pay. Discounts for essential services are offered based on family size and income. For more information, ask at the front desk or visit our website. Thank you.

AVISO PARA PACIENTES

Esta práctica sirve a todos los pacientes, independientemente de la incapacidad de pago. Descuentos para los servicios esenciales son ofrecidos dependiendo de tamaño de la familia y de los ingresos. Usted puede solicitar un descuento en la recepción o visita nuestro sitio web. Gracias.

NON-DISCRIMINATION POLICY

Haskell Memorial Hospital complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, sex, national origin, disability, religion, age, sexual orientation, or gender identity.

Haskell Memorial Hospital does not exclude people or treat them differently because of race, color, sex, national origin, disability, religion, age, sexual orientation, or gender identity.

Haskell Memorial Hospital provides free aids and services to people with disabilities to communicate effectively with us, such as:
Qualified sign language interpreters; and
Written information in other formats (large print, audio, accessible electronic formats and other formats).

Haskell Memorial Hospital provides free language services to people whose primary language is not English, such as:
Qualified interpreters; and
Information written in other languages.

If you need these services,
contact Haskell Memorial Hospital at 940-228-4321.

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NOTICE TO PATIENTS

AVISO PARA PACIENTES

NON-DISCRIMINATION POLICY