<%@LANGUAGE="VBSCRIPT"%> <% ' *** Edit Operations: declare variables MM_editAction = CStr(Request("URL")) If (Request.QueryString <> "") Then MM_editAction = MM_editAction & "?" & Request.QueryString End If ' boolean to abort record edit MM_abortEdit = false ' query string to execute MM_editQuery = "" %> <% ' *** Insert Record: set variables If (CStr(Request("MM_insert")) <> "") Then MM_editConnection = MM_msh_STRING MM_editTable = "AppInformation" MM_editRedirectUrl = "homepage.htm" MM_fieldsStr = "firstName|value|middleName|value|lastName|value|SSN|value|DOB|value|email|value|homeStreet|value|homeCity|value|homeState|value|homeZip|value|homeCounty|value|LengthResidency|value|dayPhone|value|homePhone|value|convictCrime|value|yesCrime|value|AppPosition|value|dateAvailable|value|expectedSalary|value|workedHere|value|yesWorkedWhen|value|RelFriWorkedHere|value|day7to3|value|fullTime|value|day8to5|value|partTime|value|evening3to11|value|temporary|value|night11to7|value|relief|value|Overtime|value|OtherWork|value|yesNatureofBusiness|value|bookKeeping|value|Plumber|value|Collection|value|Electrician|value|Cashier|value|HVAC|value|Switchboard|value|Carpentry|value|MedTerminology|value|Security|value|MedTranscription|value|HouseKeeping|value|Typing|value|WPM|value|GroundsCare|value|WordProcessing|value|Cook|value|Computer|value|SupportServicesOther|value|DataEntry|value|FandCother|value|LicenseState|value|LicenseNumber|value|LicensureDate|value|LicenseType|value|LicenseState2|value|LicenseNumber2|value|LicensureDate2|value|LicenseType2|value|LicenseState3|value|LicenseNumber3|value|LicensureDate3|value|LicenseType3|value|LicenseState4|value|LicenseNumber4|value|LicensureDate4|value|LicenseType4|value|hsName|value|hsYears|value|hsGrad|value|hsDate|value|hsCourse|value|colName|value|colYears|value|colGrad|value|colDate|value|colCourse|value|stName|value|stYear|value|stGrad|value|stDate|value|stCourse|value|otherName|value|otherYears|value|otherGrad|value|otherDate|value|otherCourse|value|EmployRecordDateFrom1|value|EmployRecordDateTo1|value|EmployRecordComp1|value|EmployRecordPosition1|value|EmployRecordSupervisor1|value|EmployRecordSalary1|value|EmployRecordLeaving1|value|EmployRecordDateFrom2|value|EmployRecordDateTo2|value|EmployRecordComp2|value|EmployRecordPosition2|value|EmployRecordSupervisor2|value|EmployRecordSalary2|value|EmployRecordLeaving2|value|EmployRecordDateFrom3|value|EmployRecordDateTo3|value|EmployRecordComp3|value|EmployRecordPosition3|value|EmployRecordSupervisor3|value|EmployRecordSalary3|value|EmployRecordLeaving3|value|EmployRecordDateFrom4|value|EmployRecordDateTo4|value|EmployRecordComp4|value|EmployRecordPosition4|value|EmployRecordSupervisor4|value|EmployRecordSalary4|value|EmployRecordLeaving4|value|EmployRecordDateFrom5|value|EmployRecordDateTo5|value|EmployRecordLeaving5|value|EmployRecordPosition5|value|EmployRecordSupervisor5|value|EmployRecordSalary5|value|EmployRecordLeaving5|value|ReferenceName1|value|ReferenceOccup1|value|ReferenceTelephone1|value|ReferenceAddress1|value|ReferenceName2|value|ReferenceOccup2|value|ReferenceTelephone2|value|ReferenceAddress2|value|ReferenceName3|value|ReferenceOccup3|value|ReferenceTelephone3|value|ReferenceAddress3|value|ReferenceName4|value|ReferenceOccup4|value|ReferenceTelephone4|value|ReferenceAddress4|value" MM_columnsStr = "firstName|',none,''|middleName|',none,''|lastName|',none,''|SSN|',none,''|DOB|',none,''|email|',none,''|homeStreet|',none,''|homeCity|',none,''|homeState|',none,''|homeZip|',none,''|homeCounty|',none,''|LengthResidency|',none,''|dayPhone|',none,''|homePhone|',none,''|convictCrime|none,1,0|yesCrime|',none,''|AppPosition|',none,''|dateAvailable|',none,''|expectedSalary|',none,''|workedHere|none,1,0|yesWorkedWhen|',none,''|RelFriWorkedHere|',none,''|day7to3|none,1,0|fullTime|none,1,0|day8to5|none,1,0|partTime|none,1,0|evening3to11|none,1,0|temporary|none,1,0|night11to7|none,1,0|relief|none,1,0|OverTime|none,1,0|OtherWork|none,1,0|yesNatureofBusiness|',none,''|BookKeeping|none,1,0|Plumber|none,1,0|Collection|none,1,0|Electrician|none,1,0|Cashier|none,1,0|HVAC|none,1,0|Switchboard|none,1,0|Carpentry|none,1,0|MedTerminology|none,1,0|Security|none,1,0|MedTranscription|none,1,0|HouseKeeping|none,1,0|Typing|none,1,0|WPM|',none,''|GroundsCare|none,1,0|WordProcessing|none,1,0|Cook|none,1,0|Computer|none,1,0|SupportServicesOther|',none,''|DataEntry|none,1,0|FandCother|',none,''|LicenseState|',none,''|LicenseNumber|',none,''|LicensureDate|',none,''|LicenseType|',none,''|LicenseState2|',none,''|LicenseNumber2|',none,''|LicensureDate2|',none,''|LicenseType2|',none,''|LicenseState3|',none,''|LicenseNumber3|',none,''|LicensureDate3|',none,''|LicenseType3|',none,''|LicenseState4|',none,''|LicenseNumber4|',none,''|LicensureDate4|',none,''|LicenseType4|',none,''|hsName|',none,''|hsYears|',none,''|hsGrad|none,1,0|hsDate|',none,''|hsCourse|',none,''|colName|',none,''|colYears|',none,''|colGrad|none,1,0|colDate|',none,''|colCourse|',none,''|stName|',none,''|stYear|',none,''|stGrad|none,1,0|stDate|',none,''|stCourse|',none,''|otherName|',none,''|otherYears|',none,''|otherGrad|none,1,0|otherDate|',none,''|otherCourse|',none,''|EmployRecordDateFrom1|',none,''|EmployRecordDateTo1|',none,''|EmployRecordComp1|',none,''|EmployRecordPosition1|',none,''|EmployRecordSupervisor1|',none,''|EmployRecordSalary1|',none,''|EmployRecordLeaving1|',none,''|EmployRecordDateFrom2|',none,''|EmployRecordDateTo2|',none,''|EmployRecordComp2|',none,''|EmployRecordPosition2|',none,''|EmployRecordSupervisor2|',none,''|EmployRecordSalary2|',none,''|EmployRecordLeaving2|',none,''|EmployRecordDateFrom3|',none,''|EmployRecordDateTo3|',none,''|EmployRecordComp3|',none,''|EmployRecordPosition3|',none,''|EmployRecordSupervisor3|',none,''|EmployRecordSalary3|',none,''|EmployRecordLeaving3|',none,''|EmployRecordDateFrom4|',none,''|EmployRecordDateTo4|',none,''|EmployRecordComp4|',none,''|EmployRecordPosition4|',none,''|EmployRecordSupervisor4|',none,''|EmployRecordSalary4|',none,''|EmployRecordLeaving4|',none,''|EmployRecordDateFrom5|',none,''|EmployRecordDateTo5|',none,''|EmployRecordLeaving5|',none,''|EmployRecordPosition5|',none,''|EmployRecordSupervisor5|',none,''|EmployRecordSalary5|',none,''|EmployRecordLeaving5|',none,''|ReferenceName1|',none,''|ReferenceOccup1|',none,''|ReferenceTelephone1|',none,''|ReferenceAddress1|',none,''|ReferenceName2|',none,''|ReferenceOccup2|',none,''|ReferenceTelephone2|',none,''|ReferenceAddress2|',none,''|ReferenceName3|',none,''|ReferenceOccup3|',none,''|ReferenceTelephone3|',none,''|ReferenceAddress3|',none,''|ReferenceName4|',none,''|ReferenceOccup4|',none,''|ReferenceTelephone4|',none,''|ReferenceAddress4|',none,''" ' create the MM_fields and MM_columns arrays MM_fields = Split(MM_fieldsStr, "|") MM_columns = Split(MM_columnsStr, "|") ' set the form values For i = LBound(MM_fields) To UBound(MM_fields) Step 2 MM_fields(i+1) = CStr(Request.Form(MM_fields(i))) Next ' append the query string to the redirect URL If (MM_editRedirectUrl <> "" And Request.QueryString <> "") Then If (InStr(1, MM_editRedirectUrl, "?", vbTextCompare) = 0 And Request.QueryString <> "") Then MM_editRedirectUrl = MM_editRedirectUrl & "?" & Request.QueryString Else MM_editRedirectUrl = MM_editRedirectUrl & "&" & Request.QueryString End If End If End If %> <% ' *** Insert Record: construct a sql insert statement and execute it If (CStr(Request("MM_insert")) <> "") Then ' create the sql insert statement MM_tableValues = "" MM_dbValues = "" For i = LBound(MM_fields) To UBound(MM_fields) Step 2 FormVal = MM_fields(i+1) MM_typeArray = Split(MM_columns(i+1),",") Delim = MM_typeArray(0) If (Delim = "none") Then Delim = "" AltVal = MM_typeArray(1) If (AltVal = "none") Then AltVal = "" EmptyVal = MM_typeArray(2) If (EmptyVal = "none") Then EmptyVal = "" If (FormVal = "") Then FormVal = EmptyVal Else If (AltVal <> "") Then FormVal = AltVal ElseIf (Delim = "'") Then ' escape quotes FormVal = "'" & Replace(FormVal,"'","''") & "'" Else FormVal = Delim + FormVal + Delim End If End If If (i <> LBound(MM_fields)) Then MM_tableValues = MM_tableValues & "," MM_dbValues = MM_dbValues & "," End if MM_tableValues = MM_tableValues & MM_columns(i) MM_dbValues = MM_dbValues & FormVal Next MM_editQuery = "insert into " & MM_editTable & " (" & MM_tableValues & ") values (" & MM_dbValues & ")" If (Not MM_abortEdit) Then ' execute the insert Set MM_editCmd = Server.CreateObject("ADODB.Command") MM_editCmd.ActiveConnection = MM_editConnection MM_editCmd.CommandText = MM_editQuery MM_editCmd.Execute MM_editCmd.ActiveConnection.Close If (MM_editRedirectUrl <> "") Then Response.Redirect(MM_editRedirectUrl) End If End If End If %> Untitled Document

INTERVIEWS SCHEDULED BY APPOINTMENT ONLY
This application shall be active for six months and considered only for the position for which you applied.
Equal Opportunity Employer

Monroe Surgical Hospital policy prohibits discrimination in employment based on race, color, religion, sex, national origin, physical handicap; or age with respect to individuals who are at least 18 years of age.

As a part of this application for employment by completing the following information, I hereby authorize Monroe Surgical Hospital to investigate my references, to make a confidential independent investigation of my character, conduct, employment records, to keep and preserve such records and to release all responders from any liability relating to such disclosure.

I agree that failure to reveal any prior employer or the giving of any false or misleading information by me will be grounds for termination of employment.  I understand that this employment application and any other company documents do not constitute a contract of employment and that if hired; I or Monroe Surgical Hospital may terminate my employment at any time with or without cause.

PERSONAL
First
Middle
Last
Socal Security Number Day Of Birth E-Mail
Street City State
Zip County Length of residency in community?
Day Phone Home Phone  
 
Have you ever been convicted of a crime?
If Yes, explain.

Work Information
Position applying for Date available for work Expected salary
Have you ever worked here before?  
If yes, when.
Please list relatives and/or friends working here.

What hours are you willing and available to work?
day (7-3)
full-time
day (8-5)
part-time
evening (3-11)
temporary
night (11-7 )
relief
Are you willing to work any overtime?
 
If Hired, will you be engaged in any other work or school ?
If yes, hours, days and nature of business:

FISCAL AND CLERICAL SUPPORT SERVICES
Job Skills: Check all applicable job skills that you possess.
   
Bookkeeping Plumber
Collection Electrician
Cashier HVAC
Switchboard Operator Carpentry
Medical Terminology Security
Medical Transcription Housekeeping
Typing WPM Grounds Care
Word Processing Cook
Computer Other:
Data Entry
Other:

 

LICENSURE
License and registration information for nurses and professional individuals: (list all past and present)
State: License Number: Licensure Date: LicenseType:
1.
2.
3.
4.

 

EDUCATION
High School
School Name & Address
Years Attended Graduated (check if yes) Date
Course/Major
 
College
School Name & Address
Years Attended Graduated (check if yes) Date
Course/Major
 
Special Training
School Name & Address
Years Attended Graduated (check if yes) Date
Course/Major
 
Other
School Name & Address
Years Attended Graduated (check if yes) Date
Course/Major

 

EMPLOYMENT RECORD
Account for all employment, including periods of unemployment and military training starting with most recent.
From To
Company, Address & Telephone No.
Position
Supervisor
Salary
$
Reason for leaving
From To
Company, Address & Telephone No.
Position
 Supervisor Salary
$
Reason for leaving
 
From To
Company, Address & Telephone No.
Position
 Supervisor Salary
$
Reason for leaving
 
From To
Company, Address & Telephone No.
Position
 Supervisor Salary
$
Reason for leaving
 
From To
Company, Address & Telephone No.
Position
 Supervisor Salary
$
Reason for leaving
 

 

REFERENCES
Personal References: Do not include relatives or former employers.
Name Occupation or Title Telephone
Address
 
Name Occupation or Title Telephone
Address
 
Name Occupation or Title Telephone
Address
 
Name Occupation or Title Telephone
Address