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Lodi Memorial Hospital
Online Employment Application

Use the Tab Key to move down the form, NOT the Enter Key. 
The Enter Key submits the form

Last Name

First Name

Middle Name

Email Address

Home Phone

Work Phone

Address

City

State

Zip

Are you willing to provide your Social Security No., California Drivers License No., and/or your Professional Drivers License No. at a later date?

Are you over eighteen years of age?

If you are under eighteen years of age, can you, after hire, submit a work permit?

Education (Select Highest Grade Completed)

College, School or Nursing School

Name

Address

Subject of Degree

Professional License

License Number

State

Expiration Date

Position for which you are applying (be specific)

Department (if known)

Are you willing to work on weekends?

What shifts are you willing to work?

Are you related to anyone in our company?  If Yes, to Whom and How?

As an adult, have you ever been convicted of an offense other than a minor traffic violation? If Yes, please give date and nature of the offense below (Convictions are evaluated for each osition and are not necessarily disqualifying)

Have you been employed here previously?  If Yes, please indicate Department and From/To Dates

List all jobs, full or part-time, self-employment and military service.  Please begin with your present or most recent positions.

Company Name
 

Address
 

Tel Number
 

From - To
 

Base Rate of Pay
 

Position
 

Description of Duties
 

Name and Title of Supervisor
 

Specific Reason for Termination
 

Company Name
 

Address
 

Tel Number
 

From - To
 

Base Rate of Pay
 

Position
 

Description of Duties
 

Name and Title of Supervisor
 

Specific Reason for Termination
 

Company Name
 

Address
 

Tel Number
 

From - To
 

Base Rate of Pay
 

Position
 

Description of Duties
 

Name and Title of Supervisor
 

Specific Reason for Termination
 

Company Name
 

Address
 

Tel Number
 

From - To
 

Base Rate of Pay
 

Position
 

Description of Duties
 

Name and Title of Supervisor
 

Specific Reason for Termination
 

Please indicate if you have worked under another name:

What office machines can you operate?

What plant equipment can you repair or maintain?

Foreign languages READ: (indicate fluency)

Foreign languages SPOKEN: (indicate fluency)

Personal References

Name

Address

Tel No.

Name

Address

Tel No.

Name

Address

Tel No.

Name

Address

Tel No.

I hereby certify that the information contained in this application form is true and correct to the best of my knowledge and agree to have any of the statements checked by the Hospital unless I have indicated to the contrary. I authorize the references listed above to provide the Hospital any and all information concerning my previous employment and any pertinent information that they may have. Further, I release damages that may result from furnishing such information to the Hospital as well as from the use or disclosure of such information by the Hospital or any of its agents, employees, or representatives. I understand that any misrepresentation, falsification, or material omission of information on this application may result in my failure to receive an offer or, if I am hired, in my dismissal from employment.  In consideration of my employment, I agree to conform to the rules and standards of the Hospital and agree that my employment and compensation can be terminated at will, with or without cause, and with or without notice, at any time, either at my option or at the option of the Hospital. I also understand that all offers of employment are conditioned on submitting to and successfully passing a pre-employment medical screening which includes certain lab work and a drug screening, satisfactory proof of identity, and legal authority to work in the United States. Further, I hereby certify that I am not presently under investigation for healthcare fraud, waste or abuse by any governmental agency, nor have I been limited, restricted or excluded from participating in federal healthcare programs, including, but not limited to, Medicare, MediCal or Champus.