Resumes and applications are accepted for positions at Bryan, Montpelier, and Archbold. Please complete the application below, or print by clicking here:  Application for Employment.
Return the completed application to:
Human Resources, CHWC,
433 West High,
Bryan, Ohio 43506

Note: Resumes stay on file for six months. Thank you.


APPLICATION FOR EMPLOYMENT
A resume may not be submitted in place of completing an application.
(PRE-EMPLOYMENT QUESTIONNAIRE) (AN EQUAL OPPORTUNITY EMPLOYER)
Date :  
PERSONAL INFORMATION
Social Security Number:
Name (Last, First, Middle):
List other last names used (Maiden/Prior Married):
Present Address: Permanent Address:
City, State, Zip: City, State, Zip:
Phone Number(s):
Email: Are you 18 years or older?  Yes No
Have you ever been convicted of a crime other than
minor traffic violations involving a fine of $300
or less? If yes, please describe in full.
Have you ever been excluded from participation in any
federal health care program?
 Yes No
If yes, state date of reinstatement and provide copy of letter or documentation from OIG announcing the
reinstatement.
EMPLOYMENT DESIRED
Date you can start:
Positions desired:
Shift Preference:
Do you want to work full or part time?  full Time Part Time
Are you employed now?  Yes No
If so may we inquire of your present employer?  Yes No
Have you applied to CHWC before?  Yes No
If so, when?
EDUCATION
Type of Education Name and Location of School Years
Attended
Did You
Graduate
Subjects Studied
Grammar School
High School
College
Trade, Business or
Correspondence
School
 
PROFESSIONAL LICENSE/REGISTRATION
License/Registration Number: State you are register
ed in:
Registration Effective Date: Expiration Date:
 Certified Licensed Registered Other (explain)
 
EMPLOYMENT HISTORY
List below all present and past employment, beginning with your most recent.
(NOTE: If you previously worked under another name,please indicate.)
Name and Address
of Company & Phone Number
Dates
From Mo/Yr To Mo/Yr
Position Salary Reason for Leaving Supervisor

IF YOU HAVE HAD NO PAST EMPLOYMENT

REFERENCES:

GIVE THE NAMES OF TWO PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR.

Name Address & Phone Number Business Years Acquainted

In Case of Emergency Notify:

Name Address Phone Number

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application or any other hospital document shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.

I understand and agree that, if hired, my employment relationship with CHWC will be at-will. Thus, just as I am free to end my employment with CHWC at any time for any reason, CHWC may, at any time, end my employment with CHWC at its sole discretion. I acknowledge that no supervisor, manager, or representative of CHWC, now or in the future, has authority to enter into any agreement with me for employment for any specific period of time or to make any promise or commitment contrary to the foregoing, unless that alteration
or agreement is set forth in writing and is signed by CHWC’s President.

I agree that any claim or lawsuit relating to my employment or application for employment with CHWC or any of its subsidiaries or affiliates must be filed no more than six (6) months after the date of the employment action that is the subject of the claim or lawsuit. I waive any statute of limitations to the contrary.

SIGNATURE

Date

CHWC is an equal opportunity employer. All applicants for employment are treated without regard to their race, color, religion, sex, genetic information, national origin, disability, age (forty and older), ancestry, military or veteran status, or any other status protected by applicable law. Hiring is based upon evaluation of training, experience, and other qualifications directly related to job requirements.

Thank you for completing this application form and for your interest in employment with us. We would like to assure you that your opportunity for employment with CHWC will be based only on your merit and no other consideration. This application will remain active for six (6) months.

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