Osceola Medical Center | Osceola Community Health Foundation | Wild River Fitness

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Date:
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Name (last, first, middle):(*)
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Primary Phone:(*)
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Secondary Phone:
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Salary or Wages Desired:
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Position(s) applying for:(*)
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Certification/Licensure
(number and type)
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Experience, Special Qualifications or Skills
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May we contact you by E-mail:
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E-mail Address:
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PERSONAL
Address:
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City:
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State:
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Zip Code:
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How did you find out about us?
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Explain:
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Are you over 18 years of age?
If NO, a work permit will be required.(*)
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Are you legally eligible for permanent employment in the United States?
(If hired, verification will be required by law.)(*)
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Amount of work?
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If part time or casual, list days/hours available (including AM and PM):
Monday:
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Tuesday:
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Wednesday:
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Thursday:
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Friday:
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Saturday:
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Sunday:
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Date you are available to start work:
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Have you worked for us before?
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If so, when?
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Name/Location of High School
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Did you Graduate?
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Name/Location of College
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College Major:
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Degree:
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Years Completed:
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Did you graduate?
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Name/Location of Other Education:
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Course of Study:
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Did you graduate?
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Are you employed at the present time?(*)
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If hired, will you work overtime if required?(*)
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Have you ever been bonded in prior employment?(*)
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If YES, list names of employers:
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PRIOR EMPLOYMENT
EMPLOYER 1:
Employer 1:
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Address:
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City:
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State:
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Phone:
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Employment Dates:
From:
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End:
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Position:
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Duties:
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Reason for leaving:
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Supervisor's Name:
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Starting Salary/Wages:
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Final Salary/Wages:
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EMPLOYER 2:
Employer 2:
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Address:
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City:
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State:
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Phone:
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Employment Dates:
From:
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To:
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Position:
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Duties:
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Reason for leaving:
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Supervisor's Name:
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Starting Salary/Wages:
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Final Salary/Wages:
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EMPLOYER 3:
Employer 3:
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Address:
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City:
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State:
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Phone:
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Employment Dates:
From:
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Position:
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Duties:
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Reason for leaving:
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Supervisor's Name:
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Starting Salary/Wages:
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Final Salary/Wages:
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MILITARY SERVICE:
Have you ever served in any branch of the military?(*)
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Branch of Service
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Start Date:
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End Date:
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Rank and Duties
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PROFESSIONAL REFERENCES
Name:
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Years Known:
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Daytime Phone Number:
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Relationship:
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Name:
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Years Known:
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Daytime Phone Number:
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Relationship:
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Name:
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Years known:
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Phone:
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Relationship:
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The above information is true and complete to the best of my knowledge. Should I be employed by Osceola Medical Center, any misrepresentation or false statement contained herein may be considered cause for possible dismissal. Osceola Medical Center has my permission to obtain all necessary information from the references I have listed, or any other sources, concerning my prior employment, personal history or credit standing and I release all parties from any possible damages resulting from disclosing such information with or without prior written notice to me. I reserve the right to know the names and addresses of any investigative agencies used in order that I may learn the information contained in any reports furnished to Osceola Medical Center.

I Understand this application does not constitute an employment contract of any kind. Should I be employed by Osceola Medical Center, I may resign such employment at any time at my discretion with or without prior notice and Osceola Medical center may terminate my employment at any time at their discretion, with or without cause and with or without prior notice.

IMPORTANT: By checking yes, and entering the applicant name below and by clicking Submit, you agree that you understand fully and will abide by the terms of the above notice.
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You must agree to the terms!
Name of Applicant:(*)
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