Application for Employment

POSITION INFORMATION * = required field Position Desired 1* Position Desired 2 Preferred Shift* DayEveningNight Preferred Status* Full TimePart TimeSupplemental Date Available to Start* PERSONAL INFORMATION * = required field First Name* Middle Initial Last Name* Address* City* State* Zip Code* Home Phone* E-Mail Address* Were you referred to GSRMC by anyone?* YesNoIf yes, whom? EDUCATIONAL RECORD * = required field High School Name* High School Address* Course of Study* Did You Graduate?* YesNo Diploma or Degree? DiplomaDegree College Name College Address Course of Study Did You Graduate? YesNo Diploma or Degree? DiplomaDegree Other Educational Institute Name Other Educational Institute Address Course of Study Did You Graduate? YesNo Diploma or Degree? DiplomaDegree LICENSE, REGISTRATION OR CERTIFICATION * = required field Type Number Agency Year Acquired Expiration Date State EMPLOYMENT HISTORY * = required field Company 1 Address Job Title Job Duties Supervisor's Name Phone No. Dates of Employment to Rate of Pay Reason for Leaving Company 2 Address Job Title Job Duties Supervisor's Name Phone No. Dates of Employment to Rate of Pay Reason for Leaving Company 3 Address Job Title Job Duties Supervisor's Name Phone No. Dates of Employment to Rate of Pay Reason for Leaving By submitting this online application I agree to the following: 1. To the best of my knowledge and belief, the information on this application is true. I understand that any false statements on this or any other employment form will be sufficient reason not to be considered (or continued in) employment with Good Samaritan Regional Medical Center. 2. I give Good Samaritan Regional Medical Center, Pottsville, PA, the right to investigate my education and employment background and release from liability all persons or corporations supplying information.