EMHS

Endless Care & Concern TSS

Endless Mountains Health Systems

25 Grow Avenue

Montrose, PA  18801-1199

570-278-3801

Fax 570-278-0269

EMPLOYMENT APPLICATION

Endless Mountains Health Systems is an equal opportunity employer and affords equal opportunity to all applicants for all positions without regard to race, color, religion, gender, national origin, age, disability, veteran status or any other status protected under local, state or federal laws.

 

Position(s) Applied For Date of Application

Name     Social Security Number

Address Phone Number

City State   Zip

Are you legally eligible to work in the United States?  (Proof of eligibility will be required upon offer of employment)  Yes    No

Are you over 18 years of age?   Yes    No    If no, you may be required to provide authorization.)

Have you ever applied to EMHS before?    Yes    No    If yes, please give date

Have you ever worked for EMHS before?    Yes    No    If yes, please give dates.

Have you ever been convicted of a felony?    Yes    No    If yes, explain.  (A conviction will not necessarily disqualify you for employment.)

Is anyone related to you employed at EMHS?    Yes    No

If yes, please give their name and relationship to you:   

EDUCation

  Name & Location of School Course of Study or Major # of Years Completed Diploma or Degree
High School
College
Graduate
Vocational

Please list any academic honors, scholarships, offices held, etc.

Describe any specialized training, apprenticeships, licenses or skills.

employment history

Begin with current or most recent employer.  Do not exclude any employment.  Include any applicable temporary employment and attach another sheet if necessary.  Previous salaries or wages will not be used to determine compensation at EMHS.)

Employer  

Full Address

Supervisor Your Job Title

Work Performed

Employed From to     Final Salary $

Reason for Leaving

Employer  

Full Address

Supervisor Your Job Title

Work Performed

Employed From to     Final Salary $

Reason for Leaving

Employer  

Full Address

Supervisor Your Job Title

Work Performed

Employed From to     Final Salary $

Reason for Leaving

references - Give name, complete address and phone number for work related references not related to you:

APPLICANT ACKNOWLEDGEMENT AND AUTHORIZATION RELEASE

**Please read carefully before sending**

By submitting this form I hereby certify that all of the information provided by me in this application (or any other accompanying require documents) is correct, accurate and complete to the best of my knowledge.  I understand that the falsification, misrepresentation or omission of any facts in said documents will be cause for denial or employment or immediate termination of employment regardless of the timing or circumstances of discovery.  I understand and give authorization for EMHS to request information from various federal, state, and other agencies, including public sources which maintain records concerning my past activities relating to my criminal record, previous employment, and educational background.  I understand, also, that I am required to abide by all rules and regulations of the Company.

IMPORTANT - Hit Submit, print your copy if desired, click on "Return to the form" at bottom of confirmation page then hit Reset to send form.