Online Application

PLEASE NOTE: This form uses your email program to send the completed application to us. Certain virus protection software and spam blockers will not allow your email to send the application. Please disable any virus protection or spam blocking before clicking the submit button if you are having trouble sending the information.

Personal Information
Last Name

Middle Name/Initial
 First Name

Maiden Name
Address:
City

Phone
 State

Zip Code
Social Security Number

 Position Applying For
Date Available: Now Employed? 
Wages Expected:

Education & Professional Training
High School

College
(where, years attended):
 Professional School/Training
(RN, LPN, etc.):
List Degrees, Professional License or Certificates:
Previous Employment History
List last or present employer first. Please include date of hire and termination date.
Employer 1 Dates Employed:
Employer 1 Name and Address:
Employer 1 Position Held:
Employer 1 Wages:
Employer 1 Reason for Leaving:

Employer 2 Dates Employed:
Employer 2 Name and Address:
Employer 2 Position Held:
Employer 2 Wages:
Employer 2 Reason for Leaving:

Employer 3 Dates Employed:
Employer 3 Name and Address:
Employer 3 Position Held:
Employer 3 Wages:
Employer 3 Reason for Leaving:

Employer 4 Dates Employed:
Employer 4 Name and Address:
Employer 4 Position Held:
Employer 4 Wages:
Employer 4 Reason for Leaving:

Other Questions
Name any friends or
relatives employed with
Logan Regional Medical Center

Are you legally eligible to work
in the United States?  
Is there anything else you want
us to know?
 Have you ever been
convicted of a felony?  
If so, explain:

References
Please list full name, address and phone number.
Reference 1:
Reference 2:
Reference 3:
Reference 4:
By clicking on the "Send Application" button I give my consent for Logan Regional Medical Center to check my references and any other information that I have submitted. I understand the information on this form is not being submitted over a secure server and is sent via email to the appropriate department.
PLEASE CONTACT HUMAN RESOURCES AFTER SUBMITTING TO VERIFY YOUR APPLICATION HAS BEEN RECEIVED.

 

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