Samaritan Hospital Application Page 1

4) Position Applied for:	Salary Desired:
	$ ____________
5) How were you referred to this facility:	Are you Applying:
	Full time ___ Part time ___
6) Relatives or friends employed in this facility:	Work date available:
Yes: ___ No: ___ Department:	________________
7) Have you ever been employed by this facility:	Would you consider:
Yes ___ No ___ Employment Dates:	Weekends/Holidays: Y__ N__
8) Long range occupational goals:	Rotating Shifts: Y __ N__
____________________________________________	On Call: Y__ N __
9) Are you a U.S. citizen Y __ N __; Or an alien legally authorized to work in the United States: Y __ N __	Any Shift: Y__ N __
	Any department: Y __ N __
Type of Immigration VISA:	Shift preference:
Expiration: M__ D __ Y __	Day:__ Evening:__ Night:__

10) Have you ever been convicted of a felony: Yes __ N __
If yes explain, starting with the date: M___ D ___ Y ___ Are you currently on probation: Y__ N __


11) After reviewing the functions of the position you are applying for, do you have any physical / mental reasons that would substantially limit your ability to perform the job in an appropriate and safe manner: Yes___ N ___ Do you have any special needs/requirements to perform the job: Y __ N __
School:	Name and address of school:	Course of study:	Check last year completed				Did you graduate:
High:			1_	2_	3_	4_	Yes ___
							No ___
College:			1_	2_	3_	4_	Yes:___
							No___