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. *
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