Application for
Employment

4900 Broad Road : Syracuse, New York 13215 : (315)492-5561

The policy of Community General Hospital is to provide equal opportunity to all persons, without regard to Race, Color, Religion, National Origin, Age Sex, Disability, or Veteran Status.
This application is considered current for 6 months only. At the end of this period, if you are still interested in employment, it will be necessary for you to reapply by filling out a new application.

Name:
Address:
City: State: Zip:
Phone: please include area code.
If younger than the age 18, state age:
Position applied for:
First Choice Second Choice
Date Available :
Full Time Part Time Days
Evenings NightsWeekends Only
Are you a U.S. Citizen?
Yes No
All aliens will be required to submit a copy of their Visa prior to employment
Visa Number:
Type of Visa:
Exp. Date: Month Year
How were you referred to Community General Hospital?
Walk inFormer EmployeeSelfAdvertisementSchool
Employee Referral:
Other:
Office Skills (clerical)
Typewriter WPMWord ProcessorTranscription
Medical TerminologyCRTComputer
Software Types:
Are you currently:
RegisteredLicensedCertified
RegistrationLicensureCertification
If Licensed, Registered, or Certified:
TypeState IssuedNo.Exp. Date
TypeState IssuedNo.Exp. Date
Education
Name and address of
School

Course or Major Subject

Did you Graduate?

Diploma or Degree
High School:
College:
School of Nursing:
Other:
Starting with your most recent position, list all the positions and activities including self employment and relevant volunteer experience:
Firm Name:
Supervisor's Name:
Last Salary:
Address of Firm:
Dates Employed:  From:    To:
Duties Performed:
Reasons for Leaving:
Firm Name:
Supervisor's Name:
Last Salary:
Address of Firm:
Dates Employed:  From:    To:
Duties Performed:
Reasons for Leaving:
Firm Name:
Supervisor's Name:
Last Salary:
Address of Firm:
Dates Employed:  From:    To:
Duties Performed:
Reasons for Leaving:
Applicants please read carefully before submitting:
Have you ever been convicted of a felony? Yes   No
Please explain:
I understand that falsification or the omission of any information requested will be grounds for refusal to hire, or termination. I understand that my employment is at will and can be terminated at any time.
I authorize Community Genral Hospital to contact any school, former places of employment, law enforcement agencies and/or persons who may aid in determining my suitability for employment. Additionally, I release those individuals and/or organizations contracted from all liability whatsoever for issuing the requested information.