Employee Application


Name
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Personal Information

Address
Are you at least 18 years of age?
May we contact you at work?
Are you legally eligible for employment in the U.S.?
(Proof of U.S. citizenship or status will be required upon employment)
What status are you requesting?
What shift[s] will you work?
Have you worked at any MidCoast Health System facilities in the past?
Are you presently charged with any violations of laws other than traffic violations?
Have you been convicted of a felony within the past seven (7) years?
(The existence of a conviction or pending charge will not necessarily preclude you from employment.)
Do you have family members working at the hospital?

Educational Information

(Name and Location, Years Attended, Graduated (yes or no) Degree/Diploma)
(Name and Location, Years Attended, Graduated (yes or no) Degree/Diploma)
(Name and Location, Years Attended, Graduated (yes or no) Degree/Diploma)
(Name and Location, Years Attended, Graduated (yes or no) Degree/Diploma)

Professional References

Please give four names of professional references - No family members
(Name, Occupation/Title, Address, Phone Number)
(Name, Occupation/Title, Address, Phone Number)
(Name, Occupation/Title, Address, Phone Number)
(Name, Occupation/Title, Address, Phone Number)

Employment Record

Employment History: Please list all previous employers for whom you have worked during the past five years. Explain any lapses between times when employed. ALL INFORMATION MUST BE COMPLETED FOR THE APPLICATION TO BE CONSIDERED
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Address
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Address
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Address
(computer, adding machine, X-Ray, etc.)
Have you ever been discharged from a job or forced to resign?
May we contact your present employer?
Max. file size: 300 MB.
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This field is for validation purposes and should be left unchanged.
El Campo Memorial Hospital (ECMH) and its predecessor have been providing the highest quality medical care in El Campo for over 68 years, and at the current location since 1979.The hospital is accredited by state and federal regulations (Medicare/Medicaid). Patient Billing: Various physicians involved in your care at ECMH will bill you directly for their services. These may include your anesthesiologist, emergency room physician(s), radiologist, pathologist, cardiologist or other consulting physician during your ER visit or hospital stay. Please remember that some physicians are private practitioners (contracted by ECMH and not an actual employee of ECMH) and may not be a provider on your specific managed care plan.