Employment Application

*(denotes required field)

Position(s) Applied For:

Date of Application:

Full Name:

Social Security Number:

Address:

City:

State:

Zip:

Phone Number:

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?

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

Describe any specialized training, apprenticeships, licenses or skills.

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.

CAPTCHA Code: *