General Application

Personal Data
Legal Name*
First Last
Email*
Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Are you a U.S. citizen?*
Please select your age group.*
Are you authorized to work in the United States?*

Background
Have you ever you ever worked for a LECOM Health entity?*
*If yes, when and what position?
Were you referred by a LECOM Health employee?*
*If yes, who?*
Please enter their name and entity.
Have you ever pleaded “guilty” or “ no contest” or been convicted of a crime?*
*Answering yes will not necessarily disqualify you from consideration for employment. Please Provide Details of the conviction(s) including date, conviction, and in what state it occurred:
Have you ever served in the U.S. Armed Forces?*

High School Education
High School Education*
High School Name High School Address High School Course/Major High School Year of Graduation
Did you graduate high school?*
College Education
College Education
College Name College Address College Major/Subject College Year of Graduation
Did you graduate college?*
Graduate Education
Graduate School Education
Graduate School Name Graduate School Address Graduate School Major/Subject Graduate School Year of Graduation
Did you graduate from your graduate school program?
Technical or Professional Education
Technical or Professional Education
Technical or Professional School Name Technical or Professional School Address Technical or Professional School Major/Subject Technical or Professional School Year of Graduation
Did you graduate from your technical or professional school program?
Other Education
Do you have any other education you would like to mention?
Other Education
School Name School Address School Major/Subject
Did you graduate from this program?

Professional Licenses or Certifications (Including Nursing and CPR).
Licenses or Certifications
To add more licenses or certifications, click the plus symbol on the right. You may add up to ten.
Type State Issued Registration # Effective Date Expiration Date
Work History
Are you currently employed?*
May we contact your current employer?
Please list your current job and previous three jobs.
Current Job*
Start Date End Date Employer Name and Address Position Supervisor Pay Rate Phone Number Reason for Leaving
Previous Job 1*
Start Date End Date Employer Name and Address Position Supervisor Pay Rate Phone Number Reason for Leaving
Previous Job 2*
Start Date End Date Employer Name and Address Position Supervisor Pay Rate Phone Number Reason for Leaving
Previous Job 3*
Start Date End Date Employer Name and Address Position Supervisor Pay Rate Phone Number Reason for Leaving
Please provide three references who can evaluate you in your professional capacity.
Reference 1*
Name Employer Position Telephone Email
Reference 2*
Name Employer Position Telephone Email
Reference 3*
Name Employer Position Telephone Email
If you would like to upload your resume or CV, you may do so here.
Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 5 MB, Max. files: 5.
You may upload up to five files simultaneously. Only files with extensions .doc, .docx and .pdf can be uploaded.

Application Authorization
Human Resources policies, procedures and practices will be designed to prohibit discrimination on the basis of race, color, religion, sex, national origin, age, disability, genetic information, sexual orientation, or any other type of unlawful discrimination set forth under federal, state and local law.

Employment opportunities shall be provided for applicants with disabilities and reasonable accommodation(s) shall be made to meet the physical or mental limitations of qualified applicants or employees.

I authorize Corry Memorial Hospital, or its agent to perform such investigations and inquires of my personal, employment, or medical history and other related matters as may be necessary in arriving at an employment decision. I release employers, schools or persons from all liability in responding to inquires in connection to this application for employment. Corry Memorial Hospital requires applicants who receive an offer of employment to have positive employment references, pass a physical exam, background check and drug screen.

I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of Corry Memorial Hospital.
Certification and Waiver*
I certify that all information I will provide is true, complete, and correct. Any information provided found to be false, incomplete or misrepresented in any respect, will be sufficient cause to cancel further consideration of this application, or immediately terminate me from the employer’s service, whenever it is discovered.

I authorize and request that my former/current employer, listed on this form, complete the form where indicated and release any additional information about my job performance that they may have upon receiving a further inquiry. My signature indicates my approval for this process and for the release of any such information requested during the reference. I waive all claims, any right of action, cause of action, or other means of redress related to both the completion of this form by my former/current employer and any further disclosure of information about me and I release all prior employers from whom such information is obtained from any and all liability for damages of whatever kind or nature which may at any time result to me on account of compliance, or any attempts to comply, with this authorization.

I understand that the prospective employer does not unlawfully discriminate in employment and that no question will be used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state, or federal law. Finally, to the extent I have signed with my prior employer any document by which the prior employer promised not to disclose information requested on this form, I waive all rights to enforce such a promise and release my prior employer from any such non-disclosure obligation. I certify that I have read, fully understand, and accept all terms of this statement.

By selecting yes, you agree to the above statement.
Comments
This field is for validation purposes and should be left unchanged.

General Application - LECOM Health

Step 1 of 6 - Personal Data

Personal Data

Background

Work Interest

High School Education

College Education

Graduate Education

Technical or Professional Education

Other Education

Professional Licenses or Certifications (Including Nursing and CPR).

Work History

Please list your current job and previous three jobs.

Please provide three references who can evaluate you in your professional capacity.

Application Authorization

Start Date	End Date	Employer Name and Address	Position	Supervisor	Pay Rate	Phone Number	Reason for Leaving

Type	State Issued	Registration #	Effective Date	Expiration Date