Employment Application

Contact information:
First Name:
Last Name:
Email Address:
Phone Number:
Mailing Address:
Background:
Position Desired:
Are you a U.S. citizen or an alien legally authorized to work in the United States?:
Yes No
Have you ever been convicted of a crime? If yes, please explain:

Please enter the name and address of the high school you attended, the year completed, and if a diploma was received:

Please enter the name and address of all colleges attended, course of study, years completed and any degrees received:

List any licenses and/or certifications that you have obtained, the state issued in, date of issuance, and number:

List your last place of employment and address, your title, your duties, dates of employment, and your reason for leaving:

List your previous employer, address, duties, title, dates of employment, and reason for leaving:

List your previous employer, address, duties, title, dates of employment, and reason for leaving:

Please list three professional references and their contact information:

If there is any other additional relevant information that you would like to share, please let us know:

In consideration of my employment, I agree to conform to the rules and regulations of this facility. I understand that my employment can be terminated at any time and for any reason at the option of either the facility or myself. I understand that no one has any authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing, except for a written employment agreement signed by an administrative representative of the facility. I hereby affirm that the information provided on this application is true and complete. I understand that any false or misleading representations or omissions may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date. In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non job-related disability or any other legally protected group status. Modoc Medical Center is an equal opportunity employer.