Online Employment Application

Personal Information
Todays Date
Name
Address
City
State
Zip Code
Telephone Number (Home)
Telephone Number (Work)
E-mail Address
Social Security Number
Position(s) Applied For
 
 
Date Available
Full Time
Part Time
Available to work weekends? Yes No
Please specify days and hours available
Special Skills
Typing Speed
Software Programs
Other (include machines operated)
How did you come to apply for this position? Advertisement Referral Other (please specify)
Have you ever worked at Long Beach Medical Center Before? Yes No
If yes, dates of employment
Position while employed
Supervisor's name
Reason for leaving
Have you ever applied for a position at the Medical Center before? Yes No
If yes, date of application
Position applied for
Education
High School
  
Name
Location
Type of Diploma
Degree or Certificate Earned
Major Subject
Did you graduate? Yes No
College
  
Name
Location
Type of Degree
Major
Did you graduate? Yes No
Graduate School
  
Name
Location
Type of Degree
Major
Did you graduate? Yes No
Business, Technical or Professional School
  
Name
Location
Type of Degree
Major
Did you graduate? Yes No
Highest Grade Completed
Grade School 1 2 3 4 5 6 7 8
High School 1 2 3 4
College 1 2 3 4
Graduate School 1 2 3 4
Employment History
List below all present and past employment, beginning with your most recent.
FOR ALL PERIODS OF UNEMPLOYMENT IN EXCESS OF THREE MONTHS, PLEASE GIVE AN EXPLAINATION.
Name and Address of Company 1
Employed From To
Describe your work
Weekly Starting Salary
Weekly Last Salary
Reason for Leaving
Name of Supervisor
Telephone
Name and Address of Company 2
Employed From To
Describe your work
Weekly Starting Salary
Weekly Last Salary
Reason for Leaving
Name of Supervisor
Telephone
Name and Address of Company 3
Employed From To
Describe your work
Weekly Starting Salary
Weekly Last Salary
Reason for Leaving
Name of Supervisor
Telephone
Name and Address of Company 4
Employed From To
Describe your work
Weekly Starting Salary
Weekly Last Salary
Reason for Leaving
Name of Supervisor
Telephone
May we contact the employers listed above?

Yes No

If no, indicate by number which one(s) you do NOT wish us to contact.
Military Service
Have you ever served in the United States Armed Forces? Yes No
If yes, complete the following:  
Branch
Highest Rank
Dates of Service From To
Date of Separation
Licensure - For Professional Personnel
Are you licensed or certified? Yes No
License or Certification
In what state?
Registraion number
Date of expiration
Health
Are you able, with or without reasonable accommodation, to perform the essential functions of the position for which you are applying? Yes No
If you selected no, please indicate the form of accommodation required.
References
Give names of three persons, not relatives or former supervisors.
1. Name
Address & Telephone Number
Occupation
2. Name
Address & Telephone Number
Occupation
3. Name
Address & Telephone Number
Occupation
Have you ever been convicted of any crime, other than a parking or traffic violation? Yes No
If your answer is yes, please specify nature of offense, date of conviction and sentencing.
Application Submission
By submitting this application, I understand that any employment by Long Beach Medical Center will initially be for a stated probationary period. If employed by Long Beach Medical Center, I will abide by its rules and regulations. I also agree to physical and medical examinations at any time at the option of the Medical Center, at no personal expense, and agree that the examining physician may disclose to the Medical Center or its representatives the results of such examination. I give permission to write to all or any of my pervious employers and references for full information. All of the foregoing information I have supplied in this application is a full and complete statement of the facts and it is understood that if any falsification be discovered, it will constitute grounds for dismissal upon discovery thereof.
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