Job Application

Thank you for your interest in St. Camillus Health Center. We are an equal opportunity employer that cares about the needs of our staff members. Please complete this application in its entirety.

Name*

First Last

Email*

Phone*

Current Address*

Street Address City State ZIP Code

Number of Years here*

Previous Address*

Street Address City State ZIP Code

Emergency Contact & Relationship*

Emergency Contact Phone*

Please click Yes/No below:

If under 16 years of age, do you have a work permit?

Yes
No

If you're not a U.S. citizen, do you have the right to work in the U.S.?

Yes
No

Have you ever applied for employment at St. Camillus?*

Yes
No

Have you been previously employed by St. Camillus?*

Yes
No

Were you referred by a St. Camillus Employee?*

Yes
No

Name of Employee Referral

If yes, give dates and briefly describe job you performed.

Date From:

To:

Brief description of job you performed:

Reason for leaving:

Position Applying For:*

Upload Resume

Drop files here or

Please click all that apply below

Shift(s) you can work:*

Day
Evening
Night
Weekends

Shift(s) you prefer to work:*

Day
Evening
Night
Weekends

Date you can start:*

Type of Work*

On Call
Per Diem
Part Time
Full Time

Click one below if completed with degree or certification:

High School or equivalent

Yes
No

Last grade completed

Where?

College

Yes
No

Last grade completed

Where?

Vocational or trade school

Yes
No

Last grade completed

Where?

Other related training?

Yes
No

Last grade completed

Where?

Work Experience (beginning with your most recent and working back, all jobs)

Company Name

Company Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Brief job Description

Employment dates from/to

Reason of leaving

OK to contact?

Yes
No

Company Name

Company Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Brief job Description

Employment dates from/to

Reason of leaving

OK to contact?

Yes
No

Company Name

Company Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Brief job Description

Employment dates from/to

Reason of leaving

OK to contact?

Yes
No

Personal References (no relatives or employers)

Name

Address

Phone

Name

Address

Phone

Name

Address

Phone

By submitting this form, I attest that the facts set forth in this application are true and complete. I understand that if employed, false statements on this application shall be considered sufficient cause for termination.

Name

This field is for validation purposes and should be left unchanged.

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