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Step 1 of 7 - Personal Information

14%

Name*
First Middle Last
Primary Phone*
Secondary Phone*
Current Address*
Street Address Address Line 2 City State ZIP Code
Years*
Months*
This is my permanent address*
- Yes
- No
Permanent Address*
Street Address Address Line 2 City State ZIP Code
Years*
Months*
Email*
Are you a US citizen?*
- Yes
- No
Do you have a legal right to live and work in the U.S.?*
- Yes
- No

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High School*
Major*
Date Completed*
MM slash DD slash YYYY
Graduated?*
- Yes
- No
College
Major
Date Completed
MM slash DD slash YYYY
Graduated?*
- Yes
- No
Lab/X-Ray Training School
Major
Date Completed
MM slash DD slash YYYY
Graduated?
- Yes
- No
List any other training or schools

Hit the add button for each one.
Were you in the military?*
- Yes
- No
Military Record
Military Branch*
Entry Rank*
Seperation Rank*
MOS-ADSC, Job Title, Etc.*
Separation Date(s)*
MM slash DD slash YYYY

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Professional Licenses and Certifications
Type Organization/State Issued Date Issued mm/dd/yy Number

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Type of Work (First Choice)*
Expected Salary*
Type of Work (Second Choice)
Expected Salary
Will you accept another position?*
- Yes
- No
Date You're Available to Start
MM slash DD slash YYYY
If Under 18, Do You Have a Work Permit?
- Yes
- No
When Are You Available to Work?*
- Part-Time
- Full-Time
- Any
Weekends?
- Yes
- No
Holidays?
- Yes
- No
Rotating Shifts?
- Yes
- No
On Call?
- Yes
- No
Overtime?
- Yes
- No
How Did You Learn Of This Opening?

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List three references who are not relatives or former employers*
Name and Relationship Title Company Name & Address Telephone

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Current/Most Recent Employer*
Company Phone Address City State Zip Code Position Held From - mm/dd/yy To - mm/dd/yy Reason for Leaving Explain all periods of unemployment

Click the add button to Add Another Employer
Have you ever been convicted of a crime?*
- Yes
- No
Explain*

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This institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.

I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I consent to take the preemployment physical examination, and such future physical examinations as may be required by this institution at such times and places as the institution shall designate.

I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.

If employed 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.

I understand that if employed emergency conditions may require me to temporarily work shifts other than the one for which I am applying and agree to such scheduling change as directed by my department head or administrator of this institution.
Consent*
I agree to the above conditions.
Date*
MM slash DD slash YYYY
Signature*
CAPTCHA

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Address

Washington County Memorial Hospital
300 Health Way Drive
Potosi, MO 63664

Phone: 573.438.5451
Fax: 573.438.2399

Type	Organization/State Issued	Date Issued mm/dd/yy	Number

Name and Relationship	Title	Company Name & Address	Telephone

Company	Phone	Address	City	State	Zip Code	Position Held	From - mm/dd/yy	To - mm/dd/yy	Reason for Leaving	Explain all periods of unemployment