PCHMC Secure Job Application

Online Application

I. General Information

First Name:	Middle Name:	Last Name:
Phone Number:	Phone Type:
Address:		Address2:
City:	State:	Zip:
Email:

II. Availability

Full Time: Part Time: Per Diem: Any:

Days: Nights: Evenings: Any:

III. Position(s) Applying for How did you learn of this opening?

IV. Dept. See attached list

Accounting
Ambulatory Surgery
Business Office
Chaplaincy
DOU (Step-Down)
Foundation
Housekeeping
Information Services
Medical Floor
Nuclear Medicine
OB (Obstetrics)
PBX
Public Relations
Radiology Special Proc.
Security
Transportation

Administration
Bariatric Clinic
C.T. Scan
Coding
E.R. Admitting
GI Lab
Human Resources
Lab
Medical Records
Nursery
Occupational Therapy
Pediatrics
Purchasing
Recovery
Speech Therapy
Ultrasound

Admit Unit
Bariatrics (C-Wing)
Case Management
Community Health Education
EEG
Gift Shop
ICU
Labor & Delivery
Medical Staff Services
Nursing Administration
Outpatient Radiology Clinic
Pharmacy
Quality Assurance
Respiratory Services
Surgery
Volunteer Services

Admitting
Bio-Medical Engineering
Central Supply (SPD)
Dietary
Emergency Dept.
Ground
Infection Control
Maintenance
NICU
O.B. Clinic
Pathology
Physical Therapy
Radiology
Risk Management
Surgical Unit

V. Professional Licenses Held

1.License:		State:
License #:		Expires:
2.License		State:
License #:		Expires:

VI. Certifications

CPR/BLS	ACLS	PALS	NRP
Other

VII. Questions

1. Have you been employed by us before?	Yes No
2. Do you have any relatives working here?	Yes No
3. Have you ever been convicted of a felony? **(Conviction is not an automatic bar to employment. Each case will be considered on its own merit)	Yes No
4. Are you bilingual?	Yes No
5. Do you type?	Yes No

VIII. Employment History

1. Experience

Employer 1:
City:
State:
Dates of Employment From:	To:
Department(s) Worked:
License(s) and/or Position(s) Held:
Duties:
Starting Salary:	Hourly Rate Yearly Rate
Ending Salary:	Hourly Rate Yearly Rate
Are you still employed by this employer?	Yes No
May we contact this employer?	Yes No

Employer 2:
City:
State:
Dates of Employment From:	To:
Department(s) Worked:
License(s) and/or Position(s) Held:
Duties:
Starting Salary:	Hourly Rate Yearly Rate
Ending Salary:	Hourly Rate Yearly Rate
Are you still employed by this employer?	Yes No
May we contact this employer?	Yes No

Employer 3:
City:
State:
Dates of Employment From:	To:
Department(s) Worked:
License(s) and/or Position(s) Held:
Duties:
Starting Salary:	Hourly Rate Yearly Rate
Ending Salary:	Hourly Rate Yearly Rate
Are you still employed by this employer?	Yes No
May we contact this employer?	Yes No

Employer 4:
City:
State:
Dates of Employment From:	To:
Department(s) Worked:
License(s) and/or Position(s) Held:
Duties:
Starting Salary:	Hourly Rate Yearly Rate
Ending Salary:	Hourly Rate Yearly Rate
Are you still employed by this employer?	Yes No
May we contact this employer?	Yes No

IX. Education History

1. Education

School:
City:
State:
Country:
From:	(YYYY)
To:	(YYYY)
Degree:

2. Education

School:
City:
State:
Country:
From:	(YYYY)
To:	(YYYY)
Degree:

X. Background Check Authorization

By inputting your name below, you acknowledge that a fax or copy of this Disclosure and Authorization bearing your signature shall be as valid as the original. This release is valid for all federal, state, county and local agencies and authorities.

I acknowledge the foregoing and that I have received a copy of the Summary of Rights pursuant to the Fair Credit Reporting Act (FCRA).

Full Name:

Social Security No.:

Driver's License No.: