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Name*

First name

Last name

Email*

Phone*

Address*

Street Address

Apt/Ste

City

State and Zip code

Position(s) applied for*: (Check boxes that apply)*

Administrative Assistant | Requisition #12430

Clinical Lab Scientist | Requisition #12503

Director of Patient Financial Services | Requisition #12299

Echocardiography Technician | Requisition #12470

Echocardiography Technician | Requisition #12472

Housekeeping Aide Per Diem | Requisition #12499

Nurse Practitioner | Requisition #12460

Per Diem C.S Tech Certified | Requisition #12457

Per Diem Cook | Requisition #12509

Per Diem Dietitian | Requisition #12512

Per Diem Pharmacy Technician | Requisition #12506

Rad Tech III – PM | Requisition #12501

Radiologic Technologist II – Per Diem | Requisition #12510

Radiologic Technologist II – Per Diem | Requisition #12511

Radiology Manager | Requisition #12478

Registered Nurse – Emergency Services | Requisition #12510

Registered Nurse – ICU Per Diem | Requisition #12464

Respiratory Therapist PD | Requisition #12450

SNF Director of Nursing | Requisition #12497

Earliest possible start date*

MM slash DD slash YYYY

Desired pay (Hourly/Salary)*

Highest academic level*

Subject studied/Major*

School name*

School contact*

Current or last employer name*

Job title*

Start date*

MM slash DD slash YYYY

End date

MM slash DD slash YYYY

Have you ever been terminated from employment or asked to resign by an employer*

If yes, please provide company names and details.*

Have you ever worked for Chinese Hospital before?*

If yes, please provide the start date and end date.*

Are you related to any former or current employee of Chinese Hospital?*

If yes, please provide individual name(s)*

Are you eligible to work in the U.S.?*

Are you at least 18 years or older?*

Will you now or in the future require sponsorship for employment visa to work in the U.S.?*

This includes sponsorship for H-1B, TN, or E-3 visas. Individuals currently on F-1 visas completing curricular or optional practical training should answer yes.

How did you hear about us?*

Please provide a referral name.*

Upload Resume*

Accepted file types: pdf, doc, docx, Max. file size: 1 MB.

Professional Reference (1)*

Provide name of three (3) persons, whom you have known at least three (3) years.

Name

Company/Title

Phone

Years Acquainted

Professional Reference (2)*

Name

Company/Title

Phone

Years Acquainted

Professional Reference (3)*

Name

Company/Title

Phone

Years Acquainted

Consent*

By checking this box, you agree to the Chinese Hospital Applicant Statement.

• I attest that I have provided Chinese Hospital with true and complete information on this application, and have not concealed any requested information.
• I authorize Chinese Hospital to contact the references I have provided for employment reference checks.
• I understand that if any information I have provided is untrue or if I have concealed any material information, this will be grounds for the denial of employment or immediate dismissal.

Signature*

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If you’re having trouble submitting this form, please email your resume to [email protected] with the position applied in the subject line.