Employment Application

Last Name:
First Name:
Middle Name:
Social Security Number:
Any previous names?:
If yes, identify all other names, including maiden names:
Present Address:
City:
State:
Zip Code:
Permanent Address:
Mailing Address:
Home Phone Number:
Contact Phone Number:
Email:
Position Applied For:
Hours:
Salary Desired:
Date Available for Employment:
How Were Your Referred To This Facility?:
Who do we contact in case of an emergency?
Name:
Phone:
Are you related by blood or marriage to any United Medical Centers' Board of Directors or UMC Employee:
If yes, give name, relationship, and location:
Have you previously applied for employment at UMC?:
If yes, when?:
Have you ever been employed by UMC?:
If yes, when?:
Are you under 18 years of age?:
If yes, can you provide the required proof of your eligibility to work?:
Are you a U.S. Citizen or an alien legally authorized to work in the United States?:
Long range occupational goals:
Area(s) of specialization or major interest:
Have you ever been convicted of, or plead guilty to, a crime (excluding misdemeador traffic violations)?:
If yes, explain:
Have you ever been involved in the substantiated abuse or neglect of children or adults under the laws of this or any other state of the United States (do not complete unless requested):
If yes, explain:

Education

High School

Name and Address of School:
Course of Study:
Years Completed:
Did You Graduate:
List Diploma or Degree:

Undergraduate College

Name and Address of School:
Course of Study:
Years Completed:
Did You Graduate?:
List Diploma or Degree:

Graduate/Professional

Name and Address of School:
Course of Study:
Years Completed:
Did Your Graduate?:
List Diploma or Degree:

Other (Specify)

Name and Address of School:
Course of Study:
Years Completed:
Did You Graduate?:
List Diploma or Degree:

Professional Licenses

First License

Type:
State:
Exp Date:
No.:
Currently Licensed
Eligible for License
Currently Registered
Eligible for Registration
License of Registration Ever Suspended, Revoked, or on Probation?:
If yes, explain:

Second License

Type:
State:
Exp Date:
No.:
Currently Licensed
Eligible for License
Currently Registered
Eligible for Registration
License of Registration Ever Suspended, Revoked, or on Probation?:
If yes, explain:

Professional Certifications

First Certification

Type:
State:
Date:
Currently Certified
Eligible for Certification

Second Certification

Type:
State:
Date:
Currently Certified
Eligible for Certification

Language Skills - Do Not Complete Unless Requested

First Language

Language:
Do You:
Speak
Rate Your Speaking Skills:
Read
Rate Your Reading Skills:
Write
Rate Your Writing Skills:

Second Language

Language:
Do You:
Speak
Rate Your Speaking Skills:
Read
Rate Your Reading Skills:
Write
Rate Your Writing Skills:

Specialized Skills (Skills/Equipment Operated)

Computer programs
Please list programs:
Terminal
Adding Machine
PC/MAC
Calculator
Typewriter
WPM:
Shorthand
WPM:
Other Mechanical Skills (welding, forklift operator, etc.):
Other Skills:

Work Experience

Give the names of the companies for which you have worked beginning with your present or last employer.

Employer One

Employer:
Address:
City:
State:
Zip Code:
Telephone Number(s):
Job Title:
Supervisor:
Reason for Leaving:
Dates Employed
From:
To:
Hourly Rate/Salary
Starting:
Final:
Work Performed:

Employer Two

Employer:
Address:
City:
State:
Zip:
Telephone Numbers:
Job Title:
Supervisor:
Reason for Leaving:
Dates Employed
From:
To:
Hourly Rate/Salary
Starting:
Final:
Work Performed:

Employer Three

Employer:
Address:
City:
State:
Zip Code:
Telephone Number(s):
Job Title:
Supervisor:
Reason for Leaving:
Dates Employed
From:
To:
Hourly Rate/Salary
Starting:
Final:
Work Performed:
Please identify and explain any gaps in employment longer than three (3) months:
May we contact your present employer now or later?:
Did you serve in the U.S. Armed Services?:
If yes, what branch?:
Have you volunteered your time or services?:
If yes, where?:
Briefly describe duties and skills acquired through military or volunteer service (include dates):

Personal/Professional References

Do not include family members, past supervisors, or employers

First Reference

Name:
Phone Number:
Best Time to Call:
Occupation:

Second Reference

Name:
Phone Number:
Best Time to Call:
Occupation:

Third Reference

Name:
Phone Number:
Best Time to Call:
Occupation:
Additional Information: Please give any additional information which may more fully describe your interests and qualifications.:
Upload Resume:

Read the following carefully before signing this applicationI confirm that the unformation provided in this application(and accompanying resume, of any) are true to the best of my knowledge and belief. Iunderstand that any false statements or any omission of information appearing on this or any other employment form will be sufficient reason to hireme, and if discovered after my employment, will be sufficient reason for termination. Further, UMC may conduct a detailed and thorough investigationwhich may include but is not limited to a criminal record check.I am aware that United Medical Centers is a Drug Free Workplace. I further understand that if hired, I may have to take an illegal drug and/or alcoholscreen during my employment, and that if the screen is positive, I may be terminated. Further, I understand that United Medical Centers will check mywork and other listed references. I authorize past employers, all references, and other persons to release information concerning my ability,character, reputation, and previous employment record, and I release them from any and all liability for doing so.I understand and agree that, if I am employed, my employment with United Medical Centers will be as an "at will" employee and that my employment may beterminated by me or United Medical Centers at any time with or without notice and with or without cause.I understand with this application and any other documents which I may receive are not contracts of employment.I agree to comply with United Medical Centers' rules, regulations and policies, and acknowledge that these rules, regulations and policies may bechanged, interpreted, withdrawn, or supplemented at any time, and without prior notice to me.

Signature:
Date:

Our Obstetrics & Gynecology Team will provide great care for you and your family.

Now accepting new OB/GYN patients. Call for an appointment today!