The Physicians' Hospital in Anadarko » Employment Application

Step 1 of 5 – Personal Information

Education
High School

Name and Location Major Degree
College

Name and Location Major Degree
Technical School

Name and Location Major Degree
Secondary School

Name and Location Major Degree
Other Training or GED

Name and Location Major Degree
Licensures Held

Licensure Name Licensure # Licensure Exp Date Original State Is your License Restricted? (yes or no)

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Work History
Start Date

MM slash DD slash YYYY
End Date

MM slash DD slash YYYY
Employer Name
Employer Telephone
May we contact this employer?
- Yes
- No
Employer Address

Street Address

Address Line 2

City

State

ZIP Code
Job Title
Immediate Supervisor
Hourly Rate or Salary
Job Duties
Reason for Leaving
Work History
Start Date

MM slash DD slash YYYY
End Date

MM slash DD slash YYYY
Employer Name
Employer Telephone
May we contact this employer?
- Yes
- No
Employer Address

Street Address

Address Line 2

City

State

ZIP Code
Job Title
Immediate Supervisor
Hourly Rate or Salary
Job Duties
Reason for Leaving
Work History
Start Date

MM slash DD slash YYYY
End Date

MM slash DD slash YYYY
Employer Name
Employer Telephone
May we contact this employer?
- Yes
- No
Employer Address

Street Address

Address Line 2

City

State

ZIP Code
Job Title
Immediate Supervisor
Hourly Rate or Salary
Job Duties
Reason for Leaving
Reference*

Name Phone Number Email address Years Known

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Reference*

Name Phone Number Email address Years Known

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Reference*

Name Phone Number Email address Years Known

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Military Service
Branch
Service Start Date

MM slash DD slash YYYY
Service End Date

MM slash DD slash YYYY
Type of Discharge
Rank at Discharge
Please explain other than honorable discharge:
Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Agree to Terms
- I agree to the authorization terms as listed above
Signature
In addition to work history, are there other skills, qualifications, or experience that we should consider?
Submit Your Resume
Max. file size: 80 MB.

I understand that, as a condition of my consideration for employment with The Physicians Hospital in Anadarko (“TPHA”), or as a condition of my continued employment with TPHA, TPHA may obtain a consumer report that includes, but is not limited to, my creditworthiness or similar characteristics, employment and education verifications, social security verification, criminal and civil history, personal interviews, DMV records, any other public records and any other information bearing on my credit standing, credit capacity, character, general reputation, personal characteristics and trustworthiness. I hereby authorize and consent to TPHA’s procurement of such a report. I understand that, pursuant to the federal Fair Credit Reporting Act, TPHA will provide me with a copy of any such report if the information contained in such report is, in any way, to be used in making a decision regarding my fitness for employment with TPHA. I further understand that such report will be made available to me prior to any such decision being made, along with the name and address of the reporting agency that produced the report. The following is my complete and legal name, and all information is true and correct to the best of my knowledge. By signing below I consent to the procurement of a consumer report in connection with my application for employment.
Applicant Signature:
Date*

MM slash DD slash YYYY
Name*

First

Middle

Last
ALTERNATE NAMES

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Current Address*

Street Address

City

State

ZIP Code
DRIVER’S LICENSE

Number

State
PROFESSIONAL LICENSURE VERIFICATION

Type

License Number

State
Previous Addresses

ADDRESS CITY/STATE ZIP CODE DATES (MO & YR)

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CONSENT FOR PRE-EMPLOYMENT, RANDOM, OR REASONABLE SUSPICION DRUG TEST SCREEN AND RELEASE COVENANT NOT TO SUE AND INDEMNITY AGREEMENT I hereby CONSENT to allow The Physicians Hospital in Anadarko to take a specimen of my hair, urine, or blood and submit it for a pre-employment, random, or reasonable suspicion drug test screen. I FURTHER CONSENT to allow the laboratory testing service to make the results of such screen available to the prospective or current employer, The Physicians Hospital in Anadarko. In consideration for such services being rendered on my behalf, I hereby RELEASE the laboratory testing service, its officers, agents, and employees, from any and all claims which I might otherwise have due to such results being made so available. I hereby CONSENT NOT TO FILE ANY ACTION at law or in equity against The Physicians Hospital in Anadarko, the laboratory testing service, their respective officers, agents or employees in connection with the results of such screen being made so available, and I hereby agree to INDEMNIFY and SAVE HARMLESS The Physicians Hospital in Anadarko, the laboratory testing service, their respective officers, agents, and employees from all damages, expenses, reasonable attorney's fees, and costs of court which they or any of them may suffer or incur, jointly or severally, due to the results of such screen being made so available.
Signature*
NAME*

First

Last
SIGNED this___________day of _____________, 20___.*

Employment Application

Step 1 of 5 – Personal Information

Education

Work History

Work History

Work History

Military Service

Disclaimer and Signature

The Physicians Hospital in Anadarko – Video

Mission Statement

TPHA Patient Portal

Useful Links

Licensure Name	Licensure #	Licensure Exp Date	Original State	Is your License Restricted? (yes or no)

Name	Phone Number	Email address	Years Known

Name	Phone Number	Email address	Years Known

Name	Phone Number	Email address	Years Known