Dallas County Hospital
EMPLOYMENT APPLICATION
 
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Personal
Last Name First Name Mid INIT. Email:
Home Address City State Zip
Phone US Citizen How did you hear about the position? Over 18
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
Will you accept shift work? Will you work Will you accept weekend work?
Full Time   Part Time   Temporary
Were you previously employed at a DCH facility? If Yes When                 Where Position? Under What name?
   
Have you ever been convicted of a crime? If Yes give Dates, Offense(s) and Dispositions Friend or Relative working here? - Name, Dept, Relationship
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? IF YES, A LETTER SHOWING REINSTATEMENT IS REQUIRED FOR FURTHER 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
To
Mo.               Year
Address City State Zip Position Held Ending Salary
Briefly Describe the work you performed Reason for leaving
 
From
Mo.               Year
Name of Employer Name/Title Last Supervisor Phone
To
Mo.               Year
Address City State Zip Position Held Ending Salary
Briefly Describe the work you performed Reason for leaving
 
From
Mo.               Year
Name of Employer Name/Title Last Supervisor Phone
To
Mo.               Year
Address City State Zip Position Held Ending Salary
Briefly Describe the work you performed Reason for leaving
Education
School Name of School Location Years Completed Dates Course of Study Graduate Degree
Elementry
High School
Trade
College
Graduate
Professional
Business
Other
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 and 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.