Employment Application

Applicants please note: Reynolds Memorial Hospital, Inc. is an Equal Opportunity Employer and does not discriminate on the basis of race, color, religion, sex, national origin, ancestry or disability. The Age Discrimination Act of 1967 prohibits discrimination on the basis of age. None of the information requested below will be used for any unlawful purpose.

Applications are available in the Human Resource department Mon.-Fri. 9:00 am – 3:00 pm (excluding holidays)

Personal Information

Last Name:
*
First Name:
*
MI:
Maiden or Other Name:
Social Security:
*
Phone: (including area code)
*
Are you under 18:
*
Are you a U.S. citizen or are you legally authorized to work in the United States?
*
 
 

Present Address

Address:
*
City:
*
State:
*
Zip:
*
How long have you lived at this address:
*
 
 

Position

Type of work or position(s) desired:
Type of Employment Desired:
Were you referred by a WVUM|RMH Employee:
   
If so, WVUM|RMH Employee Name:
Shift Preferred:
Can you work weekends:
 
Have you ever filed an application for Reynolds Memorial Hospital before?
Date:
 
Have you ever been employed by Reynolds Memorial Hospital before?
Position Held:
Reason for Leaving:
Are you licensed to drive a car?
License Number:
Expiration:
Have you ever been convicted or pled guilty or "no contest" to any crime(s) other than simple traffic citations?

If yes, please specify the date of conviction and nature of the crime(s)

(Please note that a conviction or plea will not necessarily result in the rejection of your application.)
 

Military Service Record

Have you ever served in the U.S. Military?
Military Duty Start Date:
Military Duty End Date:
Special training or duties while in the service:
Awards and recognition:
 

Employment Experience

Employer:
*
Job Title:
*
Employer Phone:
*
From:
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To:
*
Wage:
*
Address:
*
City:
*
State:
*
Zip:
*
Job Duties:
*
Reason for Leaving:
*
May we contact this employer:
*
Employer:
Job Title:
Employer Phone:
From:
To:
Wage:
Address:
City:
State:
Zip:
Job Duties:
Reason for Leaving:
May we contact this employer:
Employer:
Job Title:
Employer Phone:
From:
To:
Wage:
Address:
City:
State:
Zip:
Job Duties:
Reason for Leaving:
May we contact this employer:
 

Education

High School:
Highest Grade Completed:
 
Address:
City:
State:
Zip:
College:
Degree:
Year Completed:
Address:
City:
State:
Zip:
College:
Degree:
Year Completed:
Address:
City:
State:
Zip:
Business or Trade School:
Degree:
Year Completed:
Address:
City:
State:
Zip:
 

Professional Licenses

License/Certification:
State:
Expiration Date:
License/Certification:
State:
Expiration Date:
 

Personal References (Must Provide COMPLETE Address Information)

Name:
*
Phone:
*
Address:
*
City:
*
State:
*
Zip:
*
Name:
*
Phone:
*
Address:
*
City:
*
State:
*
Zip:
*
Name:
*
Phone:
*
Address:
*
City:
*
State:
*
Zip:
*
 

Statement of Applicant

For, and in consideration of, Reynolds Memorial Hospital considering my application for employment I agree as follows:

  • I certify that the answers and information given herein are true, correct, and complete to the best of my knowledge, information and belief.
  • I hereby authorize investigation of all statements contained in my application for employment by Reynolds Memorial Hospital or its agents or employees as may be necessary in arriving at an employment decision by Reynolds Memorial Hospital.
  • This application for employment shall be considered active for a period of time not to exceed six (6) calendar months. If I wish to be considered for employment beyond this time period, I shall complete a new application for employment.
  • I hereby understand and agree that if I am employed, any employment relationship of myself and Reynolds Memorial Hospital is one of “Employment-at-Will” where either party may terminate the relationship for any reason, except as may be provided by the laws of this state or the United States. Any oral representations to the contrary are not binding.
  • In the event that I am employed, I understand and agree that false or misleading information that I have given in my application or interview(s) may result in my discharge. I understand that once an offer of employment is made, I agree to complete a Post-Offer, Pre-Employment Physical Examination, the passing of which, is a term and condition of my employment.
  • I also understand that, if I am employed, I am required to abide by all policies, practices, rules and regulations of Reynolds Memorial Hospital.

Add Resume or Attachments:

Add Attachments:
   
Attachments:
No Attachments.
 

Signature

The entry of my name and e-mail address below constitutes applying my signature to this application for electronic submission.

Email:
*
Name:
*
Date:
*
How did you hear about us?