Highland District Hospital
1275 North High St.
Hillsboro, OH. 45133
937.393.6100
866.393.6100
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My HDH Records
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Mission/Vision
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Cardiopulmonary
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The Center for Rehabilitation & Sports Medicine
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Edith Brown Pavilion Geriatric Behavioral Health
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Application Form
Applicant's Information
Applicant's First Name*
Initial
Applicant's Last Name*
Address*
City*
State*
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Zip*
Cell Phone*
Alternate Phone*
Email*
Are you at least 18 years of age?*
Yes
No
Are you a US Citizen?*
Yes
No
If not a US Citizen, type of Visa?
Work Preferences
Were you previously employed by HDH?*
Yes
No
If yes, what was your title?
If yes, what was your manager?
If yes, dates of employment
If yes, under what name?
What type of employment do you prefer?*
Full-time (40 hours per week)
Part-time (less than 40 hours per week)
PRN (flexible schedule and/or hours)
What type of work will you accept?*
Full-time (40 hours per week)
Part-time (less than 40 hours per week)
PRN (flexible schedule and/or hours)
Preferred shift?*
First
Second
Third
Rotating
Date available to start?*
Position applying for (first preference)*
Wage expectation*
/hr
Position applying for (second preference)
Wage expectation
/hr
Miscellaneous
May we contact your present employer?*
Yes
No
How did you learn about us?
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Word of Mouth
Recruiter / Staffing Agency
Walk-In
Internet
Referral
Other
Have you ever been the recipient of any duty authorized sanctioning, disciplinary agency, or licensing board for either conduct or performance-based activities?
Yes
No
If yes, explain
Are you willing to work irregular schedules, overtime, and weekends when necessary?*
Yes
No
If no, explain
Education
School #1 * (Most recent)
Name of School
Location*
Course of Study*
Years Completed*
Degree or Diploma?*
Graduated?*
Yes
No
School #2
Name of School
Location
Course of Study
Years Completed
Degree or Diploma?
Graduated?
Yes
No
School #3
Name of School
Location
Course of Study
Years Completed
Degree or Diploma?
Graduated?
Yes
No
Licenses and/or Certificates
Type
Professional (e.g., RN, MT, RRT)
Issuing state or agency
Number
Expiration Date
Type
Technical (e.g., MLT)
Issuing state or agency
Number
Expiration Date
Type
Other (e.g., NA)
Issuing state or agency
Number
Expiration Date
Previous Employment
Employer #1 (Most recent)
Company*
Phone*
Address
Title
Supervisor
Start Date*
End Date
Starting Salary
Ending Salary
Job Duties*
Reason Leaving
May we contact?*
Yes
No
If no, why?
Employer #2
Company
Phone
Address
Title
Supervisor
Start Date
End Date
Starting Salary
Ending Salary
Job Duties
Reason Leaving
May we contact?
Yes
No
If no, why?
Employer #3
Company
Phone
Address
Title
Supervisor
Start Date
End Date
Starting Salary
Ending Salary
Job Duties
Reason Leaving
May we contact?
Yes
No
If no, why?
Resume / Attachments*
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