Name of Employer
Employer Phone
Type of Business
Your Supervisor's Name
Supervisor's Email
Dates of Employment:
Your position and duties
Reason for leaving
Name of Employer
Phone
Type of Business
Your Supervisor's Name
Supervisor's Email
Dates of Employment:
Your position and duties
Reason for leaving
Name of Employer
Phone
Type of Business
Your Supervisor's Name
Supervisor's Email
Dates of Employment:
Your Position and Duties:
Reason for Leaving
Name of Employer
Phone
Type of Business
Your Supervisor's Name
Supervisor's Email
Dates of Employment
Your Position and Duties:
Reason for leaving:
Name of Employer
Phone
Type of Business
Your Supervisor's Name
Supervisor's Email
Dates of Employment:
Your Position and Duties
Reason for Leaving:
Phone *
Email
Occupation *
Number of years acquainted: *
Phone *
Email
Occupation *
Number of years acquainted: *
Phone *
Email *
Occupation *
Number of years acquainted: *
1. I hereby certify that I have not knowingly withheld and information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understant that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery. *
2. I hereby authorize Community Health Systems, Inc. to thoroughly investigate my references, work record, education and other matters related to my suitability for employment (excluding criminal background information) unless otherwise specified above. I further, authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure. *
3. I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the Company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the Company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the Company's designated representative. *
4. In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire. *
Community Health Systems, Inc. will consider qualified applicants, including those with criminal histories, in a manner consistent with state and local "Fair Chance" laws. *
Date MM 1 2 3 4 5 6 7 8 9 10 11 12 / DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / YYYY 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920
