Application for Employment


This hospital is an equal opportunity employer. Federal and State laws prohibit discrimination in employment practices because of race, color, religion, age, sex, or national origin. No question on this application is asked for the purpose of limiting or excluding any applicants consideration for employment because of his or her race, color, religion, age, sex, or national origin.


Personal Information
Name
Name
Telephone
Telephone
Current Address
Current Address
Have you lived at this address for more than one year?
Please check:
Do you object to rotating shifts?
Do you object to working weekends?
Are you 18 years of age or older?
Have you ever been previously employed by Fairfield Memorial Hospital?
If yes, please provide the date, charge, and status below
If yes, please provide date, reason, and who
If yes, please provide name(s)
Are you legally entitled to work in this country?
If this application is considered favorably, on what date will you be available to work?
If this application is considered favorably, on what date will you be available to work?
Education
Graduated?
Graduated with Degree?
Graduated with Degree?
Service in U.S. Armed Forces
Have you ever served in the Armed Forces?
If yes, date of discharge:
If yes, date of discharge:
Employment
Phone Number
Phone Number
or Supervisor Number
Start date:
Start date:
End date:
End date:
Phone Number
Phone Number
or Supervisor Number
Start date:
Start date:
End date:
End date:
Phone Number
Phone Number
or Supervisor Number
Start date:
Start date:
End date:
End date:
References
(Give the names of three persons not related to you, whom you have known for at least one year.)
Name 1
Name 1
Name 2
Name 2
Name 3
Name 3
E-Signature and Confirmation
E-Signature - Please type full legal name below.
Date Signed
Date Signed
E-Signature Terms - Please Check "I Accept"
***Electronic Signature Agreement. By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide Fairfield Memorial Hospital instructions via submission, or in accessing or making any transaction regarding any agreement, acknowledgement, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and FMH. You also represent that you are authorized to enter into this Agreement for all persons who own or are authorized to access any of your accounts and that such persons will be bound by the terms of this Agreement.***