Address






Are you willing to work swing shifts?


If you are requesting employment other than regular full time, indicate your dates and times you are available:

Have you ever been convicted of a felony or misdemeanor other than traffic violations?

If yes, please describe each

Have you ever worked for Pontiac General Hospital

Type of School
Name/Address
Course of Study
Years Attended
Year Graduated
List Degree

Employers & Addresses
Dates Month & Year
Type of Work
Supervisior and Area Code & Phone Number
Salary
Reason for leaving

Employment here is for an indefinite term; it is terminable at any time by either the employee or the employer. No employee or representative of the employer except the CEO (Chief Executive Officer) has the power to commit the employer otherwise and then only if such a commitment is in a signed written document. Nothing in our Employee Reference Guide, policy or practice, shall be deemed to establish the employment of any person on a basis other than terminable at the will of either the employee or the Hospital. No oral statements otherwise shall be binding on the Hospital.

I hereby give Pontiac General Hospital permission to contact any and all former employers and associates they find necessary in determining my eligibility for employment except as noted above. I certify that the answers to the above questions are correct and that any misstatement of fact shall be sufficient cause for dismissal.



I have agreed to the conditions of employment and agree to work as stated