Submitting resume for general consideration

First Name:

Last Name:

Last Four Digits Social Security No. :

Address 1:

Address 2:

City:

State:

Zip:

Phone:

Cell Phone:

Best Time to Call:

Email:

In case of emergency, Contact:

Relationship to you:

Address:

City:

State:

Zip:

Phone:

Date Available:

Applying for:

Full Time

Part Time

Permanent

Temporary

Shift Desired:

Days (7-3:30)

Evenings (3-11:30)

Nights (11-7:30)

Any

Have you been employed previously by this hospital?

Yes

When ?

Department

Job Title

Referred By

AGENCY

EMPLOYEE REFERRAL

OWN ACCORD

OTHER

For purpose of verifying past employment please list any other names under which you have been employed:

Is U.S. Citizen?

Yes

If no, what is your Citizenship Status?

Current Occupation:

Desired Position:

Resume:

Are you eighteen years or older? (Hire subject to verification that applicant's age meets legal requirements)

Yes

If under eighteen, can you, after employment, submit a work permit?

Yes

Do you have any relatives who currently work at Jackson park hospital?(Answering yes will not disqualify you from employment.)

Yes

Relative's Name:

Relative's Position:

Relation:

www.jacksonparkhospital.org

Jackson Park Hospital and Medical Center, 7531 Stony Island Ave., Chicago, Illinois 60649

Tel: (773)-947-7500