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Lodi Memorial Hospital
Online Employment Application

Use the Tab Key to move down the form, NOT the Enter Key. 
The Enter Key submits the form

Last Name

First Name

Middle Name

Email Address

Home Phone

Work Phone

Address

City

State

Zip

Are you willing to provide your Social Security No., California Drivers License No., and/or your Professional Drivers License No. at a later date?

Are you over eighteen years of age?

If you are under eighteen years of age, can you, after hire, submit a work permit?

Education (Select Highest Grade Completed)

College, School or Nursing School

Name

Address

Position for which you are applying (be specific)

Department (if known)

Are you willing to work on weekends?

What shifts are you willing to work?

Are you related to anyone in our company?  If Yes, to Whom and How?

As an adult, have you ever been convicted of an offense other than a minor traffic violation? If Yes, please give date and nature of the offense below (Convictions are evaluated for each osition and are not necessarily disqualifying)

Have you been employed here previously?  If Yes, please indicate Department and From/To Dates

List all jobs, full or part-time, self-employment and military service.  Please begin with your present or most recent positions.

Company Name
 

Address
 

Tel Number
 

From - To
 

Base Rate of Pay
 

Position
 

Description of Duties
 

Name and Title of Supervisor
 

Specific Reason for Termination
 

Company Name
 

Address
 

Tel Number
 

From - To
 

Base Rate of Pay
 

Position
 

Description of Duties
 

Name and Title of Supervisor
 

Specific Reason for Termination
 

Company Name
 

Address
 

Tel Number
 

From - To
 

Base Rate of Pay
 

Position
 

Description of Duties
 

Name and Title of Supervisor
 

Specific Reason for Termination
 

Company Name
 

Address
 

Tel Number
 

From - To
 

Base Rate of Pay
 

Position
 

Description of Duties
 

Name and Title of Supervisor
 

Specific Reason for Termination
 

Please indicate if you have worked under another name:

What office machines can you operate?

What plant equipment can you repair or maintain?

Foreign languages READ: (indicate fluency)

Foreign languages SPOKEN: (indicate fluency)

Personal References

Name

Address

Tel No.