*POSITIONS APPLYING FOR:
1.  
2.
3.
REFERRED BY:
DATE AVAILABLE:
*SALARY REQUIREMENT:
 
 
* = REQUIRED FIELD  
Personal Information
*FIRST NAME:
 		 MI:
*LAST NAME:
 
*EMAIL ADDRESS :
 
*STREET ADDRESS:
 
*CITY:
 		 *STATE:
*ZIP CODE:
 
PLEASE LIST OTHER NAMES USED IN PAST:
*SOCIAL SECURITY NUMBER:
 
*HOME PHONE:
 
BUSINESS OR MESSAGE PHONE:
 
*HAVE YOU APPLIED AT THOUSAND OAKS SURGICAL HOSPITAL BEFORE?
IF YES, WHEN?
FOR WHAT POSITION?
*HAVE YOU BEEN PREVIOUSLY EMPLOYED BY THOUSAND OAKS SURGICAL HOSPITAL?
IF YES, WHEN?
FOR WHAT DEPARTMENT?
*ARE YOU RELATED TO ANYONE EMPLOYED BY THOUSAND OAKS SURGICAL HOSPITAL?
IF YES, WHOM?
UPON ACCEPTANCE OF AN OFFER OF EMPLOYMENT, CAN YOU PROVIDE PROOF OF U.S. CITIZENSHIP AND/OR THE LEGAL RIGHT TO WORK IN THE UNITED STATES?
*HAVE YOU EVER BEEN CONVICTED OF A FELONY? (NOTE: A "YES ANSWER IS NOT AN AUTOMATIC BAR FROM EMPLOYMENT, EACH CASE WILL BE JUDGED ON IT'S OWN MERIT.)
IF YES, STATE CIRCUMSTANCE(S), PLACE(S), DATE(S)
DO YOU READ, WRITE, OR SPEAK ANY FOREIGN LANGUAGE?
IF YES, WHICH LANGUAGE?
 
*ARE YOU APPLYING FOR:
PLEASE INDICATE THE SCHEDULE YOU ARE WILLING TO WORK (CHECK ALL THAT APPLY) :
IF PART TIME, PLEASE SPECIFY HOURS AVAILABLE: MONDAY
TUESDAY
WEDNESDAY 		THURSDAY
FRIDAY
SATURDAY 		SUNDAY
HOLIDAYS
ANY
 
Employment Record
*INSTRUCTION: LIST PRESENT OR MOST RECENT EMPLOYER FIRST, INCLUDE VOLUNTEER AND MILITARY SERVICE
*FROM:
 
*TO:
 
SALARY STARTING:
FINAL OR CURRENT SALARY
 
*COMPANY
 		 *TELEPHONE NO.:
 
*CITY:
 		 STATE:
*ZIP CODE:
 
*SUPERVISOR'S NAME :
 		 SUPERVISOR'S TITLE :
MAY WE CONTACT? :

*REASON FOR LEAVING:
 
*POSITION, DUTIES, AND SPECIALTY AREAS :
 
 
FROM:
TO:
SALARY STARTING:
FINAL OR CURRENT SALARY
COMPANY
TELEPHONE NO.:
CITY:
STATE:
ZIP CODE:
SUPERVISOR'S NAME :
SUPERVISOR'S TITLE :
MAY WE CONTACT? :

REASON FOR LEAVING:
POSITION, DUTIES, AND SPECIALTY AREAS :
 
FROM:
TO:
SALARY STARTING:
FINAL OR CURRENT SALARY
COMPANY
TELEPHONE NO.:
CITY:
STATE:
ZIP CODE:
SUPERVISOR'S NAME :
SUPERVISOR'S TITLE :
MAY WE CONTACT? :
REASON FOR LEAVING:
POSITION, DUTIES, AND SPECIALTY AREAS :
 
Education / Training
SCHOOL:
NAME AND LOCATION:
DATE ATTENDED:
ACADEMIC MAJOR:
GRADUATED?
DEGREE EARNED:
HIGH SCHOOL:
 
 
 
JUNIOR COLLEGE:
COLLEGE / UNIVERSITY:
OTHER:
 
*IF YOUR PROFESSION REQUIRES CURRENT LICENSURE, REGISTRATION, OR CERTIFICATION, PLEASE INDICATE:
TYPE:
NUMBER:
STATE:
EXPIRATION DATE:
TYPE:
NUMBER:
STATE:
EXPIRATION DATE:
 
DEPARTMENTAL EXPERIENCE (IF APPLYING FOR RN POSITION, PLEASE CHECK ALL AREAS THAT APPLY.)  
L
 
DO YOU HAVE ANY OTHER EXPERIENCE, TRAINING, QUALIFICATIONS, OR SKILLS WHICH YOU FEEL MAKE YOU SUITED FOR THOUSAND OAKS SURGICAL HOSPITAL?
 
I understand that the information I provided in this application is complete and accurate. I understand that misrepresentation, or omission of facts is cause for dismissal. I hereby authorize any previous employer to release to Thousand Oaks Surgical Hospital relevant information concerning my past employment. Further, I release all parties and persons from any and all liability for any damages that may result from furnishing such information to Thousand Oaks Surgical Hospital. I also understand that as a part of the post-offer, pre-employment process a physical examination is required.

I agree to conform to the rules and regulations of Thousand Oaks Surgical Hospital, and understand that my employment is for no definite period, and may be terminated with or without case, and with or without notice, at any time, at the option of either Thousand Oaks Surgical Hospital, or myself. I further understand that no employee, or representative of Thousand Oaks Surgical Hospital, has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the previous statement.

I understand that although I may be employed for a particular position and shift, it may be necessary to accept different assignments, work schedules, or working hours. Additionally, I acknowledge the requirement to conduct myself in a manner consistent with the mission, values and basics of Thousand Oaks Surgical Hospital.