Licensed Professional Applicants, Please Fill out the Following

P. O. Box 1369, 12th Street Extension Princeton, WV 24740

Princeton Community Hospital is an equal opportunity employer and we welcome applicants from any race, color, sex, age, religion, creed, or national origin, disability or pregnancy. Any disabled applicants will not be discriminated against pertaining to mental, physical, or visual impairment. EMPLOYMENT APPLICATION Date: APPLICANT INFORMATION Maiden/Other Full Name: Name: Street Address: City, State, Zip: Social Security Number: Phone: ( ) E-mail Address: Have you ever worked for YES NO PCH? If yes, when? Did you work for PCH under YES NO another name? If yes, name? YES NO YES NO Are you a U. S. citizen? If not, are you authorized to work in the U. S.? Based on the Immigration Reform and Control Act of 1986, all applicants must produce documents, which are specified by the Federal government, establishing their identity and authorization for employment in the United Stated once an offer of employment has been made. These documents must be produced no later than 72 hours after beginning employment. You will also be required to sign form I-9 (issued by the Federal government) verifying, under oath, your employment authorization. YES NO Position Are you under age 18? Applying For: Employmen ROTATING t FULL TIME PART TIME TEMPORARY 7 - 3 3 - 11 11 - 7 SHIFTS WEEKENDS Other: Availability: Have you ever been involuntarily discharged YES NO If yes, give dates and from a job? explain.

LICENSED PROFESSIONAL APPLICANTS, PLEASE FILL OUT THE FOLLOWING: Registration Expiration Number: State Issued: Date:

DIRECT PATIENT CARE APPLICANTS, PLEASE FILL OUT THE FOLLOWING: Have you ever been convicted of possession of any narcotic drug or controlled substance, including marijuana? YES NO (Conviction of a criminal offense does not denote automatic disqualification for employment.)

Conviction Date: City and State: Charge: Disposition:

EDUCATION High School: Address: Years YES NO Completed: Did you graduate? Degree:

College: Address: Years YES NO Completed: Did you graduate? Degree:

Other: Address: Years YES NO Completed: Did you graduate? Degree:

Other: Address:

Years YES NO Completed: Did you graduate? Degree:

Adding Skills: Typing (WPM) Shorthand (WPM) Dictaphone Machine Calculator Other

REFERENCES Please list three professional references.

Name: Occupation: Phone: ( )

Address:

EMPLOYMENT HISTORY (Complete all present and past beginning with most recent)

Company 1: Phone: ( )

Address: Supervisor:

Job Title 1: Ending Salary:

Responsibilities:

From: To: Reason for Leaving:

Responsibilities:

Please check employers we can contact. Company 1 Company 2 Company 3

MILITARY SERVICE Branch: From: To: Explain if other than Type if Discharge: honorable:

DISCLAIMER AND SIGNATURE

AFFIDAVIT: I certify that the answers given to me to the foregoing questions and statements are true and correct without consequential omissions of any kind whatsoever. I agree that my employers shall not be liable in any respect if my employment is terminated because of falsity of statements, answers or omissions made by me in this application. I authorize the employers, companies, schools or any persons named above to give any information regarding my employment, together with any information they may have regarding me whether or not is in their records. I hereby release said employers, companies, schools or persons from all liability for any damage, both legal and otherwise, for issuing this information. I also understand employment will be conditional on results of a medical examination and drug/alcohol abuse testing. In addition, if accepted for employment, I hereby agree to abide by the rules and policies of my employer.

Further, I understand that any employment is not for a stated period of time and may be terminated with or without cause, at any time, at the option of either myself or my employer.

Signed:______Date______

WE ARE AN EQUAL OPPORTUNITY EMPLOYER – A COPY OF THIS APPLICATION IS AVAILABLE TO YOU ON REQUEST.

APPLICANT: To facilitate checking your past employment and/or schools references, please signed each of the following statements that may be detached by Princeton Community Hospital and be sent to your previous employers/schools to authorize reference information.

I authorize the employers, companies, schools or persons named above to give any information regarding my employment, together with any information they may have regarding me whether or not it is in their records. I hereby release said employers, companies, schools or persons from all liability for any damage, both legal and other, for issuing this information.

Signed:______Date______APPLICANT PLEASE READ AND ACKNOWLEDGE UNDERSTANDING BY SIGNING:

This facility is an equal opportunity employer. We do not discriminate on the basis of race, religion, sex, color, national origin, age, disability or pregnancy. However, because of the large number of people that are seeking employment, we cannot possibly interview everyone that completes an application. We will, however, consider your qualifications in light of the positions we have available and based on this information and the fact we are seeking the applicant most tailored to the needs of the job, we will then schedule interviews.

PLEASE NOTE: Your application will remain active for 90 days from the date of this application for the position listed. You must reapply at the end of that time period in order to keep your application current. A separate application must be completed for each position you are interested.

TO BE COMPLETED BY PRINCETON COMMUNITY HOSPITAL

HUMAN RESOURCES – If applicant is hired, complete the following along with a PAR form.

Department Name:______Dept. Number______

Job Title:______Job Code:______

Hire Date:______Starting Date:______Processing Date:______Time:______

To replace: ______FT_____ PT______Hours:______ROP:______

Princeton Community Hospital is a general, acute care facility dedicated to providing the best possible patient care. Continuous improvement of the physical facility and its services is the hallmark of the hospital.