PAMC Personnel Application Form

531 W. COLLEGE STREET, LOS ANGELES, CA 90012
(800) 567- PAMC      www.pamc.net

 

EMPLOYMENT APPLICATION

POSITION DESIRED:

Today's Date: 5/17/2012
Professional License/Certification #: Expiration Date State
Available to Work                     
Shift Available to Work            If hired, date you can start
If hired, can you present proof of your legal right to work in this country?        

PERSONAL DATA

Last Name:   First Name:   M.I:

Address:    
City:            
State:          Other, please specify:   Zip Code/PC:
Country:    
Telephone Number:    
Web Address:
Message Telephone Number:   
Emergency Telephone Number:
Do you have any relatives working at PAMC?   
If yes, please provide name(s):
Have you been arrested for any felony?
Have you been convicted of any felony?
NOTE: A record of conviction will not necessarily disqualify you.
Have you been excluded from participating in the Medicare or Medicaid programs?
If yes, please provide reason(s):

Were you previously employed at Pacific Alliance Medical Center?
If yes, reason for leaving:

Have you worked under another name(s)?
If answer is yes, what name(s) did you use:

How did you hear about PAMC?

Name of the person who referred you to PAMC:


RECORD OF EDUCATION

School/College Name: Years attended: Major: Degree Obtained:

EMPLOYMENT RECORD
In the space provided below, list all employment or volunteer service for the past 10 years, give most recent first.

   
Employer:
Telephone Number:
Address:
Supervisor's Name:

Duties and Responsibilities:

Position:
 
From:
To:     
Salary Rate:
Starting Salary:
Ending Salary:  
Reason for Leaving:

Other languages, besides English, spoken fluently: 
Other Special Skills/Qualifications:

PERSONAL REFERENCES

Name Occupation Period Known Address Telephone Number


I certify that there are no willful misrepresentations, omissions or falsifications of the information provided on this application of employment. I understand that initial and continued employment depends on the truth and accuracy of this information and any misrepresentation will result in denial of employment or immediate termination of employment regardless of when or how discovered. I agree to submit to a physical examination after an offer of employment has been made, which may include drug screening for illegal drugs.

I authorize the investigation of all matters which Pacific Alliance Medical Center deems relevant to my qualifications for employment. I authorize Pacific Alliance Medical Center to request and receive such information and I release from all liability any persons or employers supplying it. I also release Pacific Alliance Medical Center, its officers and representatives from all liability that might result from making the investigation.

Application of employment agreement: I understand that the employment relationship at Pacific Alliance Medical Center is on an at-will basis and that if I am hired, I or PAMC may end the employment relationship at any time with or without cause with or without notice. I further understand that this provision may be modified only by the Chief Executive Officer with a signed statement specifying the specific period of employment.


 
ADDITIONAL INFORMATION