Employment Application

- Step 1 of 4

Community Health Systems, Inc. is an Equal Opportunity Employer

Date

Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Is permanent address different from present address?

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Secondary Phone Number

Employment Application

Position applying for *

Please indicate position you are applying for *

Type of work you are applying for: *

Full-time
Part-time
Temporary work (summer or holiday work)

If applying for temporary work, during what period of time will you be available?

Are you available for work on weekends? *

Are you able to work overtime, if necessary? *

If hired, what date are you able to start work? *

What days and hours are you available to work? *

How did you hear about Community Health Systems, Inc. or this job opening?

We may refuse to hire relatives of present employees if doing so could result in actual or potential problems in supervision, security, safety, or morale, or if doing so could create conflicts of interest.

Have you ever worked for Community Health Systems, Inc.? *

If yes, when?

If hired, do you have reliable means of transportation to and from work? *

Are you at least 18 years old? *

If under 18, hire is subject to verification that you are of minimum legal age.

Are you able to perform the essential functions of the jobs for which you are applying, either with or without reasonable accomodation? *

If no, describe the functions that cannot be performed.

(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.)

Education, Training, and Experience

High School *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

I graduated
I did not graduate

Diploma, GED, or other.

College/University

Address

Address Line 1

Address Line 2

City

State

Zip Code

I graduated
I did not graduate

Diploma, GED, or other.

Add a 2nd College or University

College/University

Address

Address Line 1

Address Line 2

City

State

Zip Code

I graduated
I did not graduate

Diploma, GED, or other.

Add a 3rd College or University

College/University

Address

Address Line 1

Address Line 2

City

State

Zip Code

I graduated
I did not graduate

Diploma, GED, or other.

Add a 4th College or University

College/University

Address

Address Line 1

Address Line 2

City

State

Zip Code

I graduated
I did not graduate

Diploma, GED, or other.

Vocational School

Address

Address Line 1

Address Line 2

City

State

Zip Code

I graduated
I did not graduate

Diploma, GED, or other.

Health Care Training

Address

Address Line 1

Address Line 2

City

State

Zip Code

Completion Date

Would you like to add a 2nd health care training?

Health Care Training

Address

Address Line 1

Address Line 2

City

State

Zip Code

Completion Date

Would you like to add a 3rd health care training?

Health Care Training

Address

Address Line 1

Address Line 2

City

State

Zip Code

Completion Date

Do you have any other experience, training, qualifications, or skills that you feel make you especially suited for work at Community Health Systems, Inc.? *

If so, please explain

Answer the following questions if you are applying for a professional position:

If you are not applying for a professional position, please move forward to the next section titled "Employment History"

Are you licensed/certified for the job applied for?

Name of license/certification and issuing state

License/certification number

Has your license/certification ever been revoked or suspended?

If yes, state reason(s), date of revocation or suspension, and date of reinstatement.

Would you like to add a 2nd license/certification?

Name of license/certification and issuing state

License/certification number

Has your license/certification ever been revoked or suspended?

If yes, state reason(s), date of revocation or suspension, and date of reinstatement.

Would you like to add a 3rd license/certification?

Name of license/certification and issuing state

License/certification number

Has your license/certification ever been revoked or suspended?

If yes, state reason(s), date of revocation or suspension, and date of reinstatement.

Employment History

Please list below all present and past employment, starting with your most recent employer (last 5 years is sufficient). You must complete this section even if attaching a resume.

Name of Employer

Employer Phone

Type of Business

Your Supervisor's Name

Supervisor's Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Dates of Employment:

Your position and duties

Reason for leaving

Are you currently employed there?

May we contact this employer for a reference?

Add a 2nd employer

Name of Employer

Phone

Type of Business

Your Supervisor's Name

Supervisor's Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Dates of Employment:

Your position and duties

Reason for leaving

Is this your current employer

May we contact this employer for a reference?

Add a 3rd employer

Name of Employer

Phone

Type of Business

Your Supervisor's Name

Supervisor's Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Dates of Employment:

Your Position and Duties:

Reason for Leaving

May we contact this employer for a reference?

Add a 4th employer

Name of Employer

Phone

Type of Business

Your Supervisor's Name

Supervisor's Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Dates of Employment

Your Position and Duties:

Reason for leaving:

May we contact this employer for a reference?

Add a 5th employer

Name of Employer

Phone

Type of Business

Your Supervisor's Name

Supervisor's Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Dates of Employment:

Your Position and Duties

Reason for Leaving:

May we contact this employer for a reference?

References

List below three persons not related to you who have knowledge of your work performance within the last three years.

2. Name *

First

Last

Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Occupation *

Number of years acquainted: *

2. Name *

First

Last

Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Occupation *

Number of years acquainted: *

3. Name *

First

Last

Phone *

Email *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Occupation *

Number of years acquainted: *

Please read carefully, initial each paragraph and sign below.

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//

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Community Health Systems, Inc. is an Equal Opportunity Employer

Employment Application

Education, Training, and Experience

Answer the following questions if you are applying for a professional position:

Employment History

References

Please read carefully, initial each paragraph and sign below.

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