Employment Application

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Name:

Address:

City:

State:

Zip Code:

Phone:

SSN:

Position Applying For:

Are you 16 years of age or older?
Yes No

Are you 21 years of age or older?
Yes No

Are you an American Citizen?
Yes No

If no, what documentation will you provide to prove residency or permit to work?

Proof of citizenship or immigration status will be required upon employment.

How did you learn about Minnie Hamilton Health System?

Have you ever been concvicted of, or pled guilty or no contest to a crime other than a minor traffic violation?:
Yes No

If yes, please submit in detail by fax or mail and include the date of final disposition of the case and the nature of the offense.
This information will not necessarily disqualify you from employment but false or misleading information will. Factors such as age
and time of the offenhse, seriousness and natuere of the violation, and rehabilitation will be taken into account.
Fax: 304-354-9323 or send by mail to: Shelia Gherke, MHHS, 186 Hospital Drive, Grantsville, WV 26147

Education

Name of High School:

Address:

City:

State:

Years completed:

Degree:
Diploma GED

Name of College, Technical School or Training:

Address of School:

City:

State:

Degree Type:

Area of Study:

Certifications: Y/N Exp Date

CPR:

ACLS:

PALS:

Please list other job related certifications:

Military Experience

Branch of Service:

Rank/Type of Service:

Dates Served:

Job-Related Training/Experience:

Work Experience: List Positions Starting with Most Recent

Employer:

Phone:

Dates:

Reason for Leaving:

Duties:

Employer:

Phone:

Dates:

Reason for Leaving:

Duties:

Employer:

Phone:

Dates:

Reason for Leaving:

Duties:

Employer:

Phone:

Dates:

Reason for Leaving:

Duties:

References: Do Not Include Relatives

Name:

Years Known:

Address:

Phone:

Name:

Years Known:

Address:

Phone:

Name:

Years Known:

Address:

Phone:

Minnie Hamilton Health System does not discriminate due to race, color, religion, creed, national origin, sex, age and disability, marital or veteran status in the hiring,
promotion, discharge, layoff and transferring of personnel.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

I hereby release from liability all representatives of MHHS for trheir acts in connection with the request for and receipt of references, personal or work-related, as a result of my seeking employment at MHHS.

I authorize all persons, schools, employers and other organizations mentioned in the application to provide Minnie Hamilton with any and all information requested by Minnie Hamilton related to my
qualifications for employment. I hereby release from any liability all individuals or organizations who, in good faith and without mailic, provide information to MHHS or its authorized representatives concerning
my professional competence, character , and any other qualificetions pertinent to a decision on my behalf.

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 the Employee at any time, with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by
conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

I hereby understand and acknowledge that this application is not intended an employment contract.

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.
I further understand that any job offer will be contingent upon satisfactory replies to background and reference checks. I further understand that employment with MHHS may be conditioned upon the results of a medical screening
examination, skills testing and my ability to provide satisfactory documentation of my U.S. citizenship or authorization to work in the U.S.

This application for employment shall be considered active for a period of time not to exceed 90 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 this time.

Full Legal Name:

Enter Email Address:

Date:

Minnie Hamilton Health System
186 Hospital Drive
Grantsville, WV
26147