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DCH NEWS HEALTH INFORMATION AND LINKS BOARD OF TRUSTEES NEEDS ASSESSMENT LUNCH MENU CONTACT DCH EMPLOYEE LOGIN EMPLOYMENT OPPORTUNITIES PAY BILL ONLINE ORDER FLOWERS SPRING VALLEY ASSISTED LIVING ANNUAL REPORT 2008-09 English Spanish	Back to Job Detail EMPLOYMENT APPLICATION   Click Here for the Printable Version Date of Application   Upload your Resume File: (200KB file size limit) Personal Last Name First Name Mid INIT. Email: Home Address City State Zip Phone US Citizen How Heard Over 18 Select OneYesNo Select OneYesNo LIST ANY REASON KNOWN TO YOU WHY YOU MIGHT NOT BE ABLE TO PERFORM CONSISTENTLY AND PROMPTLY ANY OF THE DUTIES Date Available Starting Salary Needed Will you accept another position If yes Specify Select OneYesNo Will you accept shift work? Will you work Will you accept weekend work? Select OneYesNo Full Time   Part Time   Temporary Select OneYesNo Were you previously employed at a DHC facility? If Yes When                 Where Position? Under What name? Select OneYesNo     Have you ever been convicted of a crime? If Yes give Dates, Offense(s) and Dispositions Friend or Relative working here? - Name, Dept, Relationship Select OneYesNo Select OneYesNo HAVE YOU EVER BEEN EXCLUDED FROM PARTICIPATION IN ANY FEDERAL OR STATE MEDICARE, MEDICAID OR ANY OTHER THIRD PARTY PAYOR PROGRAM OR HAVE SUCH PENDING ACTION? Select OneYesNo IF YES, A LETTER SHOWING REINSTATEMENT IS REQUIRED FORFURTHER CONSIDERATION FOR EMPLOYMENT. Employment History List most recent first List other names while employed with these employers From Mo.               Year Name of Employer Name/Title Last Supervisor Phone Select 1 2 3 4 5 6 7 8 9 10 11 12 To Mo.               Year Address City State Zip Position Held Ending Salary Select 1 2 3 4 5 6 7 8 9 10 11 12 Briefly Describe the work you preformed Reason for leaving   From Mo.               Year Name of Employer Name/Title Last Supervisor Phone Select 1 2 3 4 5 6 7 8 9 10 11 12 To Mo.               Year Address City State Zip Position Held Ending Salary Select 1 2 3 4 5 6 7 8 9 10 11 12 Briefly Describe the work you preformed Reason for leaving   From Mo.               Year Name of Employer Name/Title Last Supervisor Phone Select 1 2 3 4 5 6 7 8 9 10 11 12 To Mo.               Year Address City State Zip Position Held Ending Salary Select 1 2 3 4 5 6 7 8 9 10 11 12 Briefly Describe the work you preformed Reason for leaving Education School Name of School Location Years Completed Dates Course of Study Graduate Degree Elementry Select Yes No High School Select Yes No Trade Select Yes No College Select Yes No Graduate Select Yes No Professional Select Yes No Business Select Yes No Other Select Yes No Professional Licenses,Registration, and/or Certifications Do Not Include Drivers License Type State Issued Date Issued Expires Number Eligible Applicant's Certification I certify that all matters contained in this application are true, and that any misleading or false statements would render this application void and would be sufficient cause for immediate dismissal in the event of employment. I understand that this is an application for employment and that no employment contract is being offered. I hereby authorize DCH to investigate all matters contained in this application and to contact prior employers to obtain any an all information related to my past performance. I agree, if employed, to abide by all Dallas County Hospital rules and regulations. I understand that such employment is for an indefinite period of time and that the company can change wages, benefits and conditions of employment at any time. I understand that I am required to immediately notify DCH if any action is proposed to exclude me from participation in any federal or state Medicare, Medicaid or third party payor program. I have read and understand the above. Date   Signature   Important Notice to All Applicants If you are selected for employment you must be prepared to verify your eligibility to work as required under the immigration Reform and Control Act of 1986. This requirement applies to all new employees including U.S. citizens, permanent residents and nonimmigrants. You will have to provide documents within 3 days of your hire date to verify your identity and eligibility to work.
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