Employment Application

This employment application must be filled out and submitted. Submissions without a completed application will not be reviewed.

Please note that the HR department does not handle the recruitment of Physicians and Advanced Practice Providers. Physician and Advanced Practice Provider who would like to inquire about opportunities with MRMC or MCHD Partner Organizations should contact administration at (979) 241-5520 and ask for the Business Development Office.

PERSONAL

 

LAST NAME*

FIRST NAME*

MIDDLE NAME

OTHER NAME

HOME PHONE*

LAST 4 DIGITS OF YOUR SOCIAL SECURITY NUMBER*:

000-00-

STREET & NUMBER*

CITY*

STATE*

Zip Code*

PREFERRED PHONE*


US Citizen*
YESNO

IF NO, TYPE OF WORK AUTHORIZATION DOCUMENT:

EXPIRATION DATE:


LAST PREVIOUS STREET ADDRESS*:

APT. NO

CITY*

STATE*

ZIP CODE*

DATES OF RESIDENCE*

EMAIL*

JOB DATA

 

POSITION DESIRED 1*:

POSITION DESIRED 2:


SEEKING*

WILLING TO WORK OFF SHIFTS*:

LIST SHIFT PREFERENCE*:


WILLING TO WORK OVERTIME*
YESNO

AVAILABLE TO WORK WEEKENDS*
YESNO

SALARY REQUIRED*:


ARE YOU PRESENTLY EMPLOYED?* YESNO

MAY WE CONTACT YOUR PRESENT EMPLOYER?*YESNO


PREVIOUSLY EMPLOYED BY MATAGORDA COUNTY HOSPITAL DISTRICT*
YESNO

IF YES, DATES EMPLOYED:

DATE AVAILABLE FOR WORK*:

U.S. MILITARY

 

BRANCH OF SERVICE

DATE ENTERED

DATE OF DISCHARGE

RANK AT DISCHARGE

NATURE OF DUTIES AND SPECIAL TRAINING RECEIVED:

EDUCATION AND TRAINING

 

PLEASE INDICATE ANY EDUCATION, VOCATIONAL, ON-THE-JOB, OR ANY OTHER TRAINING YOU HAVE RECEIVED WHICH WILL AID US IN PLACING YOU IN THE POSITION THAT BEST MEETS YOUR QUALIFICATIONS AND/OR IN DETERMINING YOUR QUALIFICATIONS FOR A POSITION FOR WHICH YOU DESIRE TO BE CONSIDERED.


HIGH SCHOOL NAME


LOCATION OF SCHOOL

DIPLOMA, DEGREE AND/OR TRAINING RECEIVED



COLLEGE NAME


LOCATION OF SCHOOL

DIPLOMA, DEGREE AND/OR TRAINING RECEIVED


MAJOR/MINOR



GRADUATE SCHOOL NAME


LOCATION OF SCHOOL

DIPLOMA, DEGREE AND/OR TRAINING RECEIVED


MAJOR/MINOR



OTHER SCHOOL NAME


LOCATION OF SCHOOL

DIPLOMA, DEGREE AND/OR TRAINING RECEIVED


MAJOR/MINOR


FOREIGN LANGUAGE:

LANGUAGE:


TYPING SPEED

PLEASE LIST COMPUTER HARDWARE/SOFTWARE, AND ANY OTHER OFFICE EQUIPMENT USED*:


ARE YOU REGISTERED, CERTIFIED, OR LICENSED FOR ANY PROFESSION, SKILL, OR TRADE? PLEASE SPECIFY


LICENSE NO.


STATE


YEAR OBTAINED


EXPIRATION DATE


DO YOU HAVE ANY STIPULATIONS AGAINST YOUR LICENSE?*

YESNO

IF YES, EXPLAIN

GENERAL

 

HAVE YOU EVER BEEN CONVICTED OF OR BEEN ON DEFERRED ADJUDICATION FOR, OR ARE YOU NOW EITHER AWAITING TRIAL FOR OR ON DEFERRED ADJUDICATION FOR, A FELONY OR MISDEMEANOR?* YESNO


IF YES, DESCRIBE IN FULL, INCLUDING DATES AND LOCATIONS.

CONVICTION WILL NOT NECESSARILY BAR EMPLOYMENT.

WORK EXPERIENCE

INSTRUCTIONS: LIST BELOW YOUR EMPLOYMENT HISTORY, BEGINNING WITH YOUR MOST RECENT EMPLOYER. ACCOUNT FOR ALL PERIODS OF TIME INCLUDING ANY PERIODS OF UNEMPLOYMENT AND THE REASONS THEREOF. REQUESTED INFORMATION MUST BE COMPLETED, EVEN IF RESUME' ACCOMPANIES APPLICATION.


NAME OF EMPLOYER

TYPE OF BUSINESS

STREET ADDRESS

YOUR NAME AS IT APPEARED IN EMPLOYER'S RECORDS

CITY, STATE, ZIP CODE

FROM MONTH

FROM YEAR

TO MONTH

TO YEAR

STARTING PAY

FINAL PAY

NAME AND TITLE OF SUPERVISOR

TELEPHONE

JOB TITLE(S)

DESCRIPTION OF DUTIES

REASON FOR LEAVING

 


NAME OF EMPLOYER

TYPE OF BUSINESS

STREET ADDRESS

YOUR NAME AS IT APPEARED IN EMPLOYER'S RECORDS

CITY, STATE, ZIP CODE

FROM MONTH

FROM YEAR

FROM MONTH

FROM YEAR

STARTING PAY

FINAL PAY

NAME AND TITLE OF SUPERVISOR

TELEPHONE

JOB TITLE(S)

DESCRIPTION OF DUTIES

REASON FOR LEAVING

 


NAME OF EMPLOYER

TYPE OF BUSINESS

STREET ADDRESS

YOUR NAME AS IT APPEARED IN EMPLOYER'S RECORDS

CITY, STATE, ZIP CODE

FROM MONTH

FROM YEAR

TO MONTH

TO YEAR

STARTING PAY

FINAL PAY

NAME AND TITLE OF SUPERVISOR

TELEPHONE

JOB TITLE(S)

DESCRIPTION OF DUTIES

REASON FOR LEAVING

 


NAME OF EMPLOYER

TYPE OF BUSINESS

STREET ADDRESS

YOUR NAME AS IT APPEARED IN EMPLOYER'S RECORDS

CITY, STATE, ZIP CODE

FROM MONTH

FROM YEAR

TO MONTH

TO YEAR

STARTING PAY

FINAL PAY

NAME AND TITLE OF SUPERVISOR

TELEPHONE

JOB TITLE(S)

DESCRIPTION OF DUTIES

REASON FOR LEAVING

IF YOU HAVE ADDITIONAL PLACES OF EMPLOYMENT, ASK FOR AN ADDITIONAL APPLICATION


HOW WERE YOU REFERRED TO MCHD?


DO YOU HAVE RELATIVES EMPLOYED AT MCHD?*YESNO
IF SO, WHO?
DEPARTMENT
RELATIONSHIP?

 

 


I hereby certify that the information I supplied in this application is true, complete, and correct to the best of my knowledge, and I understand that any information I withheld or falsely provided in connection with the foregoing application shall be cause for rejection of this application or termination of employment. I hereby authorize Matagorda County Hospital District, without liability, to contact prior employers (present employers if authorized), schools or references I have given and authorized said employers, schools or references to make full response to any inquiries by Matagorda County Hospital District in connection with this application for Employment, including police records. I agree to observe and abide by all rules, regulations, policies and procedures of Matagorda County Hospital District.

I UNDERSTAND AND AGREE THAT IF EMPLOYED, MY EMPLOYMENT WITH THE HOSPITAL DISTRICT WILL BE AN "AT WILL" RELATIONSHIP AND MY EMPLOYMENT MAY BE TERMINATED BY ME OR THE HOSPITAL DISTRICT AT ANY TIME WITHOUT NOTICE, WITH OR WITHOUT CAUSE. I ALSO UNDERSTAND AND AGREE THAT THE "AT WILL" NATURE OF THIS RELATIONSHIP CANNOT BE MODIFIED EXCEPT BY SPECIFIC WRITTEN CONDITIONS OF MY EMPLOYMENT, INCLUDING MY COMPENSATION AND BENEFITS, CAN BE CHANGED OR TERMINATED WITHOUT CAUSE OR NOTICE AT ANY TIME BY THE HOSPITAL DISTRICT, AND THAT THE EMPLOYEE HANDBOOK, POLICY MANUAL, OR OTHER HOSPITAL COMMUNICATIONS TO EMPLOYEES ARE NOT TO BE CONSTRUED AS CREATING ANY FORM OF CONTRACT OR EMPLOYMENT AGREEMENT BETWEEN THE UNDERSIGNED AND THE HOSPITAL DISTRICT.

I understand and agree, that as a condition of employment I will be required to pass a scheduled drug/alcohol screening.
Matagorda County Hospital District promotes a smoke and drug free environment.

I HAVE READ, UNDERSTAND, AND AGREE TO THE FOREGOING PARAGRAPHS.

SIGNATURE OF APPLICANT:

DATE:

 

Attach Resume:

Attachments allowed doc,docx,pdf only.