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All potential employees are evaluated without regard to (Sabine County Hospital)

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APPLICATION FOR EMPLOYMENT
All potential employees are evaluated without regard to race, color, religion, gender, national origin, age, marital status, the presence of a
non-job related disability or any other legally protected status.
Please Print in Ink
PERSONAL
Last Name
First Name
Middle
Current/Mailing Address
E-mail Address
City
State
Zip
Social Security Number
Home Telephone Number
Cellular Telephone Number
Best time to contact you:
________ a.m. ________ p.m.
Date available for work:
Are you applying for:
Full-time Part-time
Regular Temporary
Would you consider working:
Weekends & Holidays YES NO
Rotating Shifts YES NO
On Call YES NO
Any Shift YES NO
Shift Preference:
Days
Evenings
Nights
Are you a U.S. citizen or an alien legally authorized
to work in the United States?
YES NO If employed, I understand I am
required to complete Form I-9 to show evidence of
identity and eligibility for employment.
Position Applied for:
Salary desired:
How did you learn about this position? If from a Hospital employee, please indicate whom?
Relative or friends employed here? YES NO
Name: Dept: Relationship:
Have you been employed here in the past? YES NO If yes, when:
Are you 18 years of age or older? YES NO
Long Range Occupational Goals:
Have you ever been convicted of, or plead guilty to a crime (excluding misdemeanor traffic violations)? YES NO
If yes, explain:
Have you ever been involuntarily terminated or asked to resign from any position of employment? YES NO
If yes, please describe circumstances:
EDUCATION/SKILLS
School
Name and Address of School
Last year completed
Did you graduate?
List diploma or degree
High
1 2 3 4
YES NO
College
1 2 3 4
YES NO
College
1 2 3 4
YES NO
2301 Worth Street
Hemphill, Texas 75948
Telephone: (409) 787-3300
Fax: (409) 787-1010
www.sabinecountyhospital.com
Briefly describe other skills or special courses (include special military training, post graduate and nursing).
PROFESSIONAL LICENSES/CERTIFICATIONS
Type:
State:
Date:
Number:
Type:
State:
Date:
Number:
Type:
State:
Date:
Number:
EMPLOYMENT HISTORY
Enter information for your last 3 employers – starting with the most recent.
Employer
Duration of Employment
From: To:
Address (City & State)
Name of Supervisor
Position Title
Phone Number
Reason for Leaving
If this is your current employer, may we contact them?
Yes No
Employer
Duration of Employment
From: To:
Address (City & State)
Name of Supervisor
Position Title
Phone Number
Reason for Leaving
If this is your current employer, may we contact them?
Yes No
Employer
Duration of Employment
From: To:
Address (City & State)
Name of Supervisor
Position Title
Phone Number
Reason for Leaving
If this is your current employer, may we contact them?
Yes No
REFERENCES
Name
Phone Number
Name
Phone Number
Name
Phone Number
IMPORTANT – READ BEFORE SIGNING
I hereby affirm that the information provided on this application (and accompanying resume) is true and correct. I understand
that any false or misleading representations or omissions made on the application or during the hiring process may disqualify me
from further consideration for employment and may result in discharge even if discovered at a later date.
I understand that my employment may be contingent upon successfully passing a medical examination, physical therapy
assessment, drug test, and criminal background check.
I hereby authorize persons, schools, my current employer (if applicable) and previous employers and other organizations to
provide this facility and its affiliates with any requested information regarding my application or suitability for employment, and I
completely release all such persons or entities from any and all liability related to the providing or use of such information.
I understand that my employment is at will which means that I may terminate the employment relationship at any time and for
any reason with or without notice, and that the facility has the same right.
In the event of employment, I will be required to complete an Employment Verification Form (I-9) and within three days show
satisfactory evidence of identity and eligibility for employment.
_______________________________________________ ___________________
Signature of Applicant Date
PLEASE ATTACH RESUME’
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Completed 15 August 2021

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