Position Applying For * Please note the position you are applying for. Can request to be kept on file. Applicant Full Name * Contact Information Email Address Contact Phone What is the best time to reach you? - None -MorningAfternoonEveningNight Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Availability Information Are you at least 16 years of age? * - Select -YesNo Do you have a legal right to work in the US? * - Select -YesNo What shifts can you work? * Days Evenings Nights Weekends Alternating Weekends Only Please select all that apply. Availability * Fulltime (40 hrs/wk.) Part Time Regular Temporary Summer Only On Call Please check all that apply. Number of hours desired Available start date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20192020202120222023 Education Information Highest level of Education - None -Primary SchoolHigh School Diploma / GEDSome CollegeA.A.S DegreeBachelors DegreeGraduate / Masters DegreePhd / MD School Name (Higher Education) Degree(s) Obtained License/Certification InformationTo be completed by registereed, licensed, or certified applicants License Number State Expiration Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2019202020212022202320242025 Employment Record Previous or Current Employer * May we contact your present employer? * - Select -YesNo Dates Employed Supervisor Name Supervisor Phone Job Duties at Previous Employer Reason for leaving Salary Employer 2 Previous Employer #2 Dates Employed #2 Supervisor Name #2 Supervisor Phone #2 Job Duties at Previous Employer #2 Reason for leaving #2 Salary #2 Employer 3 Previous Employer #3 Dates Employed #3 Supervisor Name #3 Supervisor Phone #3 Job Duties at Previous Employer #3 Reason for leaving #3 Salary #3 ReferencesReference 1 Name - Reference #1 * Phone - Ref #1 * Occupation - Ref #1 * Reference 2 Name - Reference #2 Phone - Ref #2 Occupation - Ref #2 Reference 3 Name - Reference #3 Phone - Ref #3 Occupation - Ref #3 Additional Information Comments Upload your resume Acceptable formats: Word Documents (.doc, .docx) / Acrobat files (.pdf) / Text documents (.txt, .rtf). Maximum file size 4MB.Files must be less than 4 MB.Allowed file types: txt rtf pdf doc docx. Agreement By submitting this online form I authorize the investigation of all statements contained in this application. I understand that misrepresentation or omission of information in connection with my application and/or interview will be sufficient cause, in and of itself, for rejection or dismissal whenever discovered. I understand and agree that any offer of employment is dependent upon satisfactory completion of a pre-employment investigation which includes but is not limited to education and work history verification, reference checks and any investigation required by local, state, or federal laws. I understand that if I am hired by Stevens Community Medical Center or any of its affiliates or subsidiaries, my employment will be for an indefinite period of time and will be “at will”, which means that either I or Stevens Community Medical Center may terminate the employment relationship at any time and for any or no reason. I further understand that, if hired, my at-will employment status may only be changed in a written contract signed by the President of Stevens Community Medical Center or the President’s authorized representative, and that no representative of Stevens Community Medical Center has the authority to make any oral promise to me concerning my employment. Finally, I also understand that while Stevens Community Medical Center supports current policies and benefits, it retains the right to change them at any time, with or without notice. Stevens Community Medical Center is an Equal Employment Opportunity Employer committed to providing a safe, healthy and productive work environment and supports a smoke free, alcohol and drug-free environment. I have Read and agree to the Agreement above * - Select -YesNo CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.