Guam Regional Medical City Employment Application Form
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4HR USE ONLY
Date Received:
Notes:__________________________
EMPLOYMENT APPLICATION FORM
_______________________________
_______________________________
READ THE FOLLOWING INSTRUCTIONS CAREFULLY BEFORE FILLING OUT THE APPLICATION:
Please answer all items on this application, where applicable. Take time to list pertinent information, including references, carefully and
completely. Failure to do so may prevent consideration for a position for which you are applying. All information provided by the
applicant on this form is subject to verification. Inability on our part to confirm statements made by you may prevent consideration for
employment.
We take all appropriate action to comply with all applicable laws of the Territory of Guam and the United States Federal Government
regarding employment practices. Guam Regional Medical City (GRMC) is an equal opportunity employer and does not discriminate on the
basis of age, race, religion, sex, color, national origin, mental or physical disability, political affiliation, sexual orientation, matriculation, marital
status, family responsibility, or personal appearance.
PLEASE ANSWER ALL APPLICABLE QUESTIONS COMPLETELY. PLEASE TYPE OR PRINT LEGIBLY IN BLACK OR BLUE INK.
PERSONAL
NAME: (LAST)
(FIRST)
(MI
DATE OF APPLICATION
APPLICATION ADDRESS: (NUMBER AND STREET NAME, APARTMENT NO)
(CITY)
(STATE)
(ZIP CODE)
TELEPHONE NUMBER:
E-MAIL ADDRESS:
HOME: (
)
-
WORK: (
)
-
CELL: (
)
-
HAVE YOU EVER APPLIED FOR A POSITION AT GUAM REGIONAL MEDICAL CITY
YES
NO
HAVE YOU BEEN EMPLOYED BY A HOSPITAL PREVIOUSLY?
DATES
DEPARTMENT
YES
NO
ARE YOU LEGALLY AUTHORIZED TO WORK IN THE UNITED STATES?
ARE YOU 18 YEARS OR OLDER
YES
NO
YES
NO
POSITION(S) DESIRED
POSITION(S ) APPLYING FOR
DEPARTMENT:
STATUS DESIRED:
1.
FULL TIME
PART TIME
ON CALL
PER DIEM
TEMP
SHIFT PREFERENCE:
2.
DAY
EVENING
NIGHT
ROTATING
WEEKEND
WHEN CAN YOU BEGIN WORK:
MINIMUM ACCEPTABLE SALARY:
3.
As the hospital is on a 7-day schedule, it may be necessary to work any shift, weekend, or holiday, as needed. Also, you may be
hired for a specific work week or shift and later be required to change your work week or shift. Normally, you will be given a two-
week notice of such a change.
I accept these conditions of employment:
YES
NO
IF NO, PLEASE EXPLAIN:
EDUCATION / TRAINING
Type of School
Name and Address of School
Years Attended
Did You
Major Study Course / Degree
Graduate
Obtained
High School
Undergraduate College
or University
Graduate College or
University
Technical Training
Institution
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