GUTHRIE TOWANDA

MEMORIAL HOSPITAL

91 Hospital Drive

Towanda, PA 18848

APPLICATION FOR EMPLOYMENT

DRUG FREE WORK FORCE

Last NameFirst NameMiddle Name / Application Date
Current Address: (Number & Street) / Home Phone / Cell Phone
City, State & Zip
Email Address
EMPLOYMENT DESIRED
First Choice: / Second Choice:
Have you worked for Guthrie before? Yes No
If "Yes," date left / Will you accept part time work?
Yes No / Will you accept temporary work?
Yes No
Have you worked for Guthrie before under another name?
Yes No If "Yes," state name / Shift or hours you can work
1st 2nd 3rd / Other
U.S. MILITARY SERVICE
Have you served in the U.S. Military?
Yes No
Please list job-related skills or experience.
PERSONAL
Have you, since the age of 18, ever been Yes If "Yes," explain and give dates:
convicted of a misdemeanor or felony? No / NOTE: A conviction will not necessarily bar you from employment
Have you ever been involuntarily discharged from a job? Yes No If "Yes," Explain:
EDUCATION
Names & Complete Addresses
High School: / Diploma: ______(yes) ______(no) or
GED: ______(yes) ______(no)
College or University: / Academic Major:
Technical or Vocational:
REFERENCES
Name / Occupation / Organization
Phone # / Address
Name / Occupation / Organization
Phone # / Address
Name / Occupation / Organization
Phone # / Address
EXPERIENCE
Last Employment First / Give a complete record of all employment and reasons or periods unemployed during past ten years. Start with most recent employment.
Do not omit any employers in the past ten years.
Mo / Yr / Mo / Yr / Employer's Name Address & Phone Number / Last Salary and Positions Held / Reasons for Leaving
Employer:
Street:
City, State & Zip:
Phone #: / Salary:
Position:
Supervisor:
Employer:
Street:
City, State & Zip:
Phone #: / Salary:
Position:
Supervisor:
Employer:
Street:
City, State & Zip:
Phone #: / Salary:
Position:
Supervisor:
Employer:
Street:
City, State & Zip:
Phone #: / Salary:
Position:
Supervisor:
May we contact your present employer for a reference?
Yes No / List machines/equipment you can use related to the position for which you are applying:
PROFESSIONAL LICENSES, REGISTRATIONS, AND/OR CERTIFICATIONS
Type / State Issued / Date / Number
Type / State Issued / Date / Number
SUBSTANCE ABUSE POLICY - Pre-placement testing for drugs and alcohol: All applicants, after being offered employment will be required to undergo testing for the presence of illegal drugs and alcohol. Applicants who test positive and are verified as positive by the Medical Review Officer will not be eligible for hire.
INFORMATION RELEASE I give my consent for you to verify my former employment and/or academic records to Guthrie Towanda Memorial Hospital and to supply the information requested. I release you from any liability connected with the submission of the requested information.
______
Signature

Were you referred by an employee of Guthrie Towanda Memorial Hospital? ______Yes ______No

If so, who referred you? ______