Application for Employment

HAGERSTOWN, MD | DRIVING DIRECTIONS
PHONE: 301-733-0330 / 1-800-342-2992

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Application for Employment

You may download the pdf or fill out the online form below.

To Applicant: We appreciate your interest in our organization and assure you that we are interested in your qualifications. A clear understanding of your background and work history will aid us in placing you in the position that best meets your qualifications.

Personal

First Name:
Middle:
Last Name:
Present Address:
City:
State:
Zip:
Telephone:
Email:

Are your legally eligible for employment in the U.S.A.? YesNo

Sex : MaleFemale

Age if under 18 or over 70

Do you have a valid driver's license in your state of residence? YesNo

Driver's License
State No. Class

Have you ever had your driver's license suspended or
revoked in the past ten years? YesNo

If yes, explain:

Address on license if different than above

Address:
City:
State:
Zip:

Position(s) applied for:

Rate of pay expected ($ per week):

Were you previously employed by us? YesNo

If yes, when?

List any friends or relatives working for us:

Date you will be available for work:

Are there any experiences, skills, or qualifications which you feel would especially fit you for work with our organization?

Have you ever been convicted of a crime in the past ten years which has not been annulled or expunged or sealed by a court? YesNo

If yes, describe in full:

NOTE: Police record check is a condition of employment.
TIP and CPR training is a condition of employment for selected staff.

Record of Education

High School

Course of Study

Years Completed 1234

Did you Graduate? YesNo

List diploma or degree:

Undergraduate College or University

Course of Study

Years Completed 1234

Did you Graduate? YesNo

List diploma or degree:

Graduate College or University

Course of Study

Years Completed 1234

Did you Graduate? YesNo

List diploma or degree:

Supervised Training Experience

Course of Study

Years Completed 1234

Did you Graduate? YesNo

List diploma or degree:

Professional Licensure & Certifications

State of Licensure & Certification:

Dates Licensed/Certified:

License Number:

Have you ever been denied or lost clinical privileges at another hospital? YesNo

If yes, please explain:

Have there been any previous successful or currently pending challenges to your licensure or registration in any state or district? YesNo

If yes, please explain:

Have you ever been involved in a professional liability action? YesNo

If yes, please explain:

Employment History (beginning with most recent)

Company
Address:
City:
State:
Zip:
Telephone:

Dates employed:

Describe the work you did:

Weekly starting salary:

Weekly last salary:

Reason for leaving:

Name of Supervisor:

Company
Address:
City:
State:
Zip:
Telephone:

Dates employed:

Describe the work you did:

Weekly starting salary:

Weekly last salary:

Reason for leaving:

Name of Supervisor:

Company
Address:
City:
State:
Zip:
Telephone:

Dates employed:

Describe the work you did:

Weekly starting salary:

Weekly last salary:

Reason for leaving:

Name of Supervisor:

Company
Address:
City:
State:
Zip:
Telephone:

Dates employed:

Describe the work you did:

Weekly starting salary:

Weekly last salary:

Reason for leaving:

Name of Supervisor:

May we contact the employers above? YesNo

If not, indicate which one(s) you do not wish us to contact?

Personal References (not former employers or relatives)

Name and Occupation

Address:
City:
State:
Zip:
Telephone:

Personal References (not former employers or relatives)

Name and Occupation

Address:
City:
State:
Zip:
Telephone:

Personal References (not former employers or relatives)

Name and Occupation

Address:
City:
State:
Zip:
Telephone:

Under Maryland law an employer may not require or demand any applicant for employment or prospective employment or any employee to submit to or take a polygraph, lie detector or similar test or examination as a condition of employment or continued employment. Any employer who violates this provision is guilty of a misdemeanor and subject to a fine not to exceed $100.00.

Please read below:

The facts set forth in my application for employment are true and complete. I understand that if employed, false statements on the application shall be considered sufficient cause for dismissal. You are hereby authorized to make any investigation of my personal history and financial and credit record through any investigative or credit agencies or bureaus of your choice.

In making this application for employment I authorize you to make an investigative consumer report whereby information is obtained through personal interviews with my neighbors, friends, or others with whom I am acquainted. This inquiry, if made, may include information as to my character, general reputation, personal characteristics and mode of living. I understand that I have the right to make a written request within a reasonable period of time to receive additional, detailed information about the nature and scope of any such investigative report that is made.

I have read and agree to the terms above

Authorization for release of information

In connection with my employment application now on file with Brook Lane Health Services, Hagerstown, Maryland, I hereby authorize the release of information concerning my employment with your company.

Name:

If you have been employed under any other name, please list that name below:

1-800-342-2992
(301) 733-0330
FAX (301) 733-4038

13218 Brook Lane Drive
P.O. Box 1945, Hagerstown, MD 21742


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