Secure Application for Employment
Human Resources Department
704 Hospital Drive
Carrizo Springs, Texas 78834
email:  tdube@dimmitregional.com
Date
This application can be active as long as legally required.
Last Name                                    First Name                                  Middle Initial
   
Are You At Least 18 Years Old?

Home Phone And Cell Phone

Present Address

Present City

Present State

Present Zip Code

E-Mail Address

Previous Address

Previous City

Previous State

Previous Zip

Current Open Position(s) for Which You Are Applying



Type of Position
Per Diem
Pool
Full Time
PRN
Part Time
Temporary
Shift Available

Weekend
Day
Night
Evening
Rotation
Salary Desired
$
Are You Willing To Travel?

Are You Willing To Relocate?

If overtime work is required periodically, does this pose a problem for you?
Date Available For Work

Are You Legally Authorized to Work in the U.S.?
Have you ever worked in this or any other facility?
If yes, what facility? Are you related to another facility employee or Board Member?

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How did you learn about this position?
State Employment
         Commission
Internet
Agency
Ad
Job Listing
School
Current Employee
Job Line
Other:

Are you able to perform the essential, job related functions of the position for which you are applying with or without reasonable accommodations?
Describe any accommodations necessary:

Have you ever been convicted of a felony (conviction of such crime does not constitute an absolute bar to employment)?

If yes, give date, place and nature of each such conviction.

Are you currently excluded from participation in any federally funded healthcare program - including Medicare and Medicaid - and are you
aware of any potential exclusion from a federally funded health program?
Educational History
Type of School
Name of School

City, State
Check Last Year
Attended in School

Degree or Certificate
High School
School:
    City:
   State:
9   10   11   12
Graduated/GED?
Degree:
College
School:
    City:
   State:
1     2     3    4
Graduated?
Degree:
College
School:
    City:
   State:
1    2    3     4
Graduated?
Degree:
Graduate
School

School:
    City:
   State:
1    2     3    4
Graduated?
Degree:
Other
School:
    City:
   State:
1    2    3    4
Graduated?
Degree:
Other
School:
    City:
   State:
1    2    3    4
Graduated?
Degree:
List any professional licenses, registration or certification you possess
Include Type, State Issued, Expiration Date and Number.
Indicate if any licenses have been revoked, suspended or placed on probation.
Also indicate if you are ineligible to become licensed or certified in your field. Please explain.

Clerical or other skills applicable to the position for which you are applying
Typing (WPM)
Proficient in Software: 
Business machines and/or equipment you can operate:
      
Other