Serious

1. Healthcare Workforce Initiative
1111 South Edwin C. Moses Blvd.
P.O. Box 972
Dayton, OH 45422
Employment Application
Position Applied for: Nursing Assistant Environmental Services Worker Nutrition Services Worker
Applicant Information
Full Name: Date:
Last First M.I.
Address:
Street Address Apartment/Unit #
City State ZIP Code
Phone: E-mail Address:
Social Security Desired Shift: Desired Status:
Date Available: No: - - 1st 2nd 3rd F/T P/T or Resource
Charles F. Kettering Memorial Hospital Kettering Medical Center-Sycamore
Hospital Location Desired: Grandview Medical Center Southview Hospital Kettering Hospital Youth Svcs.
How did you hear about the HWI Program?
KMCN Employee Job Bank KMCN Website Other:
Education
High School: Address:
YES NO If not, do you YES NO
Did you graduate? have a GED?
College: Address:
YES NO
Did you graduate? Degree:
Other: Address:
YES NO
Did you graduate? Degree:
Employment References
Please list three employment references (Preferably from an immediate supervisor or manager)
Full Name: Title:
Company: Phone: ( ) -
Address:
Full Name: Title:
Company: Phone: ( ) -
Address:
Full Name: Title:
Company: Phone: ( ) -
Address:
Employment Application
Rev. 6/30/08

2. Previous Employment
Account for ALL times for the past 10 years, including periods of unemployment. If you need more room, use a separate
piece of paper. A RESUME is both welcomed and urged in addition to completion of this application.
Company: Phone: ( ) -
Address: Supervisor:
Job Title: Starting Salary: $ Ending Salary: $
Responsibilities:
Reason for
From: To: Leaving:
YES NO
May we contact your previous supervisor for a reference?
Company: Phone: ( ) -
Address: Supervisor:
Job Title: Starting Salary: $ Ending Salary: $
Responsibilities:
Reason for
From: To: Leaving:
YES NO
May we contact your previous supervisor for a reference?
Company: Phone: ( ) -
Address: Supervisor:
Job Title: Starting Salary: $ Ending Salary: $
Responsibilities:
Reason for
From: To: Leaving:
YES NO
May we contact your previous supervisor for a reference?
YES NO
Are you authorized to work in the U.S.?
Have you ever worked for the Kettering YES NO If yes, when and at which facility?
Medical Center Network?
Have you ever been convicted of a crime for the violation of any law , excluding minor traffic tickets?
Yes No
If Yes, describe all of these actions, including the nature of the criminal offense(s), the location(s), the dates and their disposition.
Conviction of a crime is not an automatic bar for consideration for employment. Falsification of information will result in rejection of
application. (If necessary, use a separate piece of paper):
If yes, explain:
Employment Application
Rev. 6/30/08

3. Additional Previous Employment
Company: Phone: ( ) -
Address: Supervisor:
Job Title: Starting Salary: $ Ending Salary: $
Responsibilities:
Reason for
From: To: Leaving:
YES NO
May we contact your previous supervisor for a reference?
Company: Phone: ( ) -
Address: Supervisor:
Job Title: Starting Salary: $ Ending Salary: $
Responsibilities:
Reason for
From: To: Leaving:
YES NO
May we contact your previous supervisor for a reference?
Company: Phone: ( ) -
Address: Supervisor:
Job Title: Starting Salary: $ Ending Salary: $
Responsibilities:
Reason for
From: To: Leaving:
YES NO
May we contact your previous supervisor for a reference?
Employment Application
Rev. 6/30/08

4. Disclaimer and Signature
***********************************STOP HERE—PRINT, SIGN, AND DATE APPLICATION **********************************
I understand that my employment thereof is contingent upon positive results of a successful pre-placement physical, including drug
screen analysis, criminal background checks and possible fingerprinting. The result of such analysis may be grounds for
disqualifying me or terminating my employment.
I authorize schools, references, my prior employers and physicians or other medical practitioners to provide my record, reason for
leaving, and other information they may have concerning me to Montgomery County Department of Job & Family Services and
Kettering Medical Center Network and I release all parties from any and all liability to claims for damage whatsoever that may result
there from.
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand
that false or misleading information in my application or interview may result in my release.
Signature: Date:
Employment Application
Rev. 6/30/08