Camden-Clark Memorial Hospital

Personnel Department
800 Garfield Avenue  Parkersburg, WV  26101    (304) 424-2205

Application for Employment

An Equal Opportunity Employer

If assistance is needed due to a disability, 
a Personnel Representative will be available for assistance upon request.

First Name    MI    Last Name  
                 
Phone: (Include area code)                                   

Present Address: (Include Street, City, State & Zip)
 
   
How long have you lived at this address?  

Are you under 18?                  Select One Yes No      U.S. Citizen?                  Select One Yes No

Are you presently addicted to habit forming drugs (narcotics)?                Select One Yes No
If yes, please explain: 

I understand that, as a condition of employment, I must submit and successfully pass a drug and alcohol screening test.
       Initials                 

Type of work or position desired:
Shift preferred:
Type of employment desired:   Select One Permanent Temporary                      Select One Full-Time Part-Time Either
Can you work weekends?                  Select One Yes No
Have you ever filed an application for Camden-Clark before?               Select One Yes No
Date:
Have you ever been employed by Camden-Clark Memorial Hospital?               Select One Yes No
Position held:
Reason for leaving:

Can you type?                 Select One Yes No       If yes, words per minute
Are you licensed to drive a car?                  Select One Yes No
License number:   State:   Expiration:

Military Service Record

Have you ever served in the Military Service of the U.S.?                  Select One Yes No
Dates of duty: From       to
Special training or duties while in the service: 

Awards and recognition: 

Employment Experience
List each job held. Start with your present or last job. Include military service assignments and volunteer activities.

Personal References
List below three individuals who have knowledge of your character. Do not list relatives or employers. These references may be contacted prior to hiring.

Education

Select highest grade completed:                  Select One 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Licensure/Certification:
      State:      Expiration Date:

Licensure/Certification:
      State:      Expiration Date:

The following statement is part of this application. Read it carefully and sign below.

It is understood and agreed that any misrepresentation by me in this application shall be sufficient cause of cancellation of the application and/or separation from Camden-Clark Memorial Hospital. If I am employed by the Hospital, employment is affirmed upon the successful completion of an employment physical examination paid by the Hospital, and I will be an at-will employee, and have no contract of employment with the hospital. I understand that my employment may be terminated by the Hospital or by me, at any time for any reason or for no reason at all. Camden-Clark Memorial Hospital is an Equal Employment Opportunity Employer.

The entry of my name and e-mail address below constitutes applying my signature to this application for electronic submission.

Name: 
E-mail Address:  
Date: 
How did you hear about us?