Type of Employment Desired:  Please Select an option:     Full-Time Pool Seasonal

* Drivers License (last 4 numbers only)         * State
     

* Are you a citizen of the United States of America?    Yes No   

If no please explain:


* Have you ever been convicted or awaiting trial for any violation of the law? (exclude traffic violations)  Yes No

If yes please explain:


* Were you ever discharged or forced to resign from any position?  Yes No

If yes please explain:


* EDUCATION

                                                       Name & Location                 Dates                    Graduate?          Degree or Certification
    High School                                                                      
       
  College/University                                       

  Graduate School                                         

  Vocational School                                       
  or Special Training          

Professional License or Certification (If Required)                    Number  (leave blank)       Exp Date
               

* Employment History
 
Starting with the most recent or present experience, please provide the following information for all.

Employer 1
From:                            To:                             Employer:                                                           Telephone:
                 
Job Title:                                                         Address:
    
Reason For Leaving:                                        Final Salary/Hourly Rate:     


Employer 2
From:                            To:                             Employer:                                                           Telephone:
                 
Job Title:                                                         Address:
    
Reason For Leaving:                                        Final Salary/Hourly Rate:     


Employer 3
From:                            To:                             Employer:                                                           Telephone:
                 
Job Title:                                                         Address:
    
Reason For Leaving:                                        Final Salary/Hourly Rate:     


Note: Springhill Medical Services, Inc requires as a condition of employment, the successful completion of a chemical screen and medical examination to determine that all individuals hired are free of communicable disease, free of controlled substances in the body and are able to sufficiently perform job duties.

Certification of Applicant (Carefully read before submitting)

I certify that all statements made in this application and attachments are true and complete to the best of my knowledge and that any misstatement of material fact may subject me to disqualification or dismissal.  I also agree to allow Springhill Medical Services, Inc to obtain a criminal, credit (if required for the position) and any other job related information about me. 

* DO YOU AGREE WITH THIS STATEMENT?   YES NO     Submit   

Springhill Medical Services, Inc is an Equal Opportunity Employer