Seminole Hospital District

Please complete this application to the best of your ability.

Fields marked with a * are required. If these fields are not filled out, the form will not submit.

By submitting an application, you give the Seminole Hospital District permission to contact previous employers and references for review.

Personal Information

First Name: *		Last Name: *
Address: *		City: *
State: *		Zip: *
Home Phone: *	( ) -	Cell Phone:	( ) -
Email: *

Position Applying For:
Shift Preferred:	1 2 3 Any NA
Type of Work Desired:	Full-time Part-time Seasonal Temporary
Do you have a legal right to work in the USA?	Yes No (If yes, proof is required to be hired.)
If you are under 18, can you provide a work permit if required?	Yes No
On what date would you be available to work?
Have you been employed here before?	Yes No

How were you referred to us?

If driving may be required in the job for which you are applying, please provide your driver's license number.
Driver's License Number:

Education

High School
Name:	Location:
Degree or Diploma:	Did you graduate?	Yes No

College
Name:	Location:
Course of Study:	Did you graduate?	Yes No
Degree or Diploma:

Graduate School
Name:	Location:
Course of Study:	Did you graduate?	Yes No
Degree or Diploma:

Vocational or Other Training
Name:	Location:
Course of Study:	Did you graduate?	Yes No
Degree or Diploma:

Continuing Education

Special Training or Skills (languages, machine operation, etc.) that would benefit you in the job for which you are applying.

Employment Experience

Please list most recent employment first.

1. Employer: *		Address: *
Position: *		Supervisor: *
Employed	From: Year: *		Starting Rate Yr. Hr.
	To: Year: *		Ending Rate Yr. Hr.
Reasons for leaving.

2. Employer:		Address:
Position:		Supervisor:
Employed	From: Year:		Starting Rate Yr. Hr.
	To: Year:		Ending Rate Yr. Hr.
Reasons for leaving.

3. Employer:		Address:
Position:		Supervisor:
Employed	From: Year:		Starting Rate Yr. Hr.
	To: Year:		Ending Rate Yr. Hr.
Reasons for leaving.

4. Employer:		Address:
Position:		Supervisor:
Employed	From: Year:		Starting Rate Yr. Hr.
	To: Year:		Ending Rate Yr. Hr.
Reasons for leaving.

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