Millinocket Regional Hospital | Employment Application

Current/Most Recent Job

Company

Date Started (Month and Year)

Date Ended (Month and Year)

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Phone Number

Your name while employed

Immediate supervisor's name

May we contact them?

Job Title

Salary

Duties

Schedule

Hours per week?

Reason for leaving

1st Previous Job

Company

Date Started (Month and Year)

Date Ended (Month and Year)

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Phone Number

Your name while employed

Immediate supervisor's name

May we contact them?

Job Title

Salary

Duties

Schedule

Hours per week?

Reason for leaving

2nd Previous Job

Company

Date Started (Month and Year)

Date Ended (Month and Year)

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Phone Number

Your name while employed

Immediate supervisor's name

May we contact them?

Job Title

Salary

Duties

Schedule

Hours per week?

Reason for leaving

3rd Previous Job

Company

Date Started (Month and Year)

Date Ended (Month and Year)

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Phone Number

Your name while employed

Immediate supervisor's name

May we contact them?

Job Title

Salary

Duties

Schedule

Hours per week?

Reason for leaving

Personal Reference 1

Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Number of years known*

Position*

Phone*

Personal Reference 2

Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Number of years known*

Position*

Phone*

Personal Reference 3

Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Number of years known*

Position*

Phone*

Please Review and Acknowledge That You Understand The Following.

In making application for employment:

* I certify that the information in this application is true and complete for all practical purposes. It may be verified by the facility or any affiliate. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the facility or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.

* I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable. If such an investigative report is made, I understand that I will receive notice that such a report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.

I UNDERSTAND AND AGREE THAT IF I AM OFFERED EMPLOYMENT BY THE FACILITY, MY EMPLOYMENT WILL BE FOR NO DEFINITE TERM AND THAT EITHER I, OR THE FACILITY WILL HAVE THE RIGHT TO TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, I ALSO UNDERSTAND THAT THIS STATUS CAN ONLY BE ALTERED BY A WRITTEN CONTRACT OF EMPLOYMENT WHICH IS SPECIFIC AS TO ALL MATERIAL TERMS AND IS SIGNED BY ME AND THE ADMINISTRATOR OF THE FACILITY.

Release:
I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my licensure status and my licensure history.

I agree that I will settle any and all claims, disputes or controversies arising out of or relating to my application for employment, employment or termination of employment with the employer exclusively by final and binding arbitration and before a neutral Arbitrator and in accordance with the rules and procedures for employment disputes adopted by the employer. Such claims shall include those that could be brought in a court of law under any applicable federal, state or local statutory or common law, such as the Age Discrimination in Employment Act, Title VII of the Civil Rights Act of 1964, as amended, including the amendments of the Civil Rights Act of 1991, the Americans with Disabilities Act, the Family and Medical Leave Act, state civil rights acts, the law of contract and the law of tort.

I have read and understand these conditions of employment*

Yes

Applicant's full name*

Resume / CV

Accepted file types: pdf, doc, docx, Max. file size: 8 MB.

If you have a copy of your resume in Adobe PDF or Microsoft Word format, please attach it here.

Employment Application

Step 1 of 4

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Current/Most Recent Job

1st Previous Job

2nd Previous Job

3rd Previous Job

Personal Reference 1

Personal Reference 2

Personal Reference 3

Billing & Insurance

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