Online Application
FIRST NAME
LAST NAME
 MI
 SOCIAL SECURITY NUMBER
CURRENT ADDRESS
CITY
 ZIP CODE
STATE
STATE
 ZIP CODE
PERMANENT ADDRESS
CITY
PHONE NUMBER
CELL NUMBER
ARE YOU A U.S. CITIZEN?
 IF NO, ALIEN REGISTRATION NUMBER:
YES
NO
POSITION  FOR WHICH YOU ARE APPLYING
 EXPECTED SALARY
OTHER POSITIONS FOR WHICH YOU ARE QUALIFIED
IF YES, LIST DATES, DEPARTMENTS, AND TITLES
HAVE YOU WORKED HERE BEFORE?
 DATE AVAILABLE TO START WORK
YES
NO
MAY MAKE MULTIPLE
SELECTIONS
HOURS AVAILABLE TO WORK
HOURS DESIRED IF PT
SHIFT PREFERENCE
WILL YOU TAKE ANY SHIFT?
DAY
FULL TIME
PART TIME
SUMMER
TEMPORARY
YES
 NO
EVENING
ARE YOU AVAILABLE WEEKENDS?
NIGHT
YES
NO
EDUCATION
 
NAME AND LOCATION OF SCHOOL
NUMBER OF YEARS
COMPLETED
DID YOU
GRADUATE/
PROMOTE?
MAJOR COURSE/DEGREE RECEIVED
ELEMENTARY
YES
NO
HIGH SCHOOL
YES
NO
COLLEGE
YES
NO
TRADE/
BUSINESS
YES
NO
OTHER
YES
NO
SPECIAL QUALIFICATIONS AND SKILLS
LICENSE OR CERTIFICATE
 LICENSING AUTHORITY
 LICENSE NUMBER
 DATE OF LICENSE
       
BUSINESS, HOSPITAL, INDUSTRIAL EQUIPMENT OPERATED  
       
TYPING SPEED
 SHORTHAND SPEED
 OTHER QUALIFICATIONS or SKILLS
  
 
       
WORK EXPERIENCE (INCLUDE MILITARY EXPERIENCE) starting with your present or last place of employment
DATE EMPLOYED
NAME AND
ADDRESS OF
EMPLOYER
CASH SALARY
POSITION HELD
REASON FOR
LEAVING
TO
START
FINISH
TO
START
FINISH
TO
START
FINISH
TO
START
FINISH
MAY WE CONTACT YOUR PRESENT EMPLOYER?  
YES
NO
REFERENCES (OTHER THAN RELATIVES)
NAME
ADDRESS
PHONE
OCCUPATION
ARE THERE ANY FACTORS THAT WOULD LIMIT YOUR PERFORMANCE IN THIS POSITION? IF SO, EXPLAIN.
EMAIL ADDRESS

This institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship,national origin, ancestry, political
beliefs, or in the basis of age or physical or mental disability unrelated to the ability to perform the work required. No question on this application
is intended to secure information to be used for such discrimination.

I voluntarily give this institution the right to make a thorough investigation on my past employment and activities, agree to cooperate in such
investigation and release  from liability or responsibility all persons, companies and corporations supplying such information. I consent to take
the pre-employment physical examination, and such future physical examinations as may be required by this institution at such times and places
as the institution shall designate.

I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also
understand that my employment will be terminated for any misstatement or omission of fact on this application form.

If employed, I will be required to complete an Employment Verification Form (I-9) and within three days show satisfactory evidence of identity and
eligibility for employment.
SUBMISSION OF THIS APPLICATION IS VERIFICATION THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE.
Wilbarger General Hospital is an equal opportunity employer.