Chennai Hospitals Private Limited
932-A, Sathy Road, Gandhipuram, Coimbatore - 641 012.
E-mail : careers@chennaihospitals.com www.chennaihospitals.com
APPLICATION FOR EMPLOYMENT
What is the best time Post applied for Job reference No.
to contact you by telephone?
PLEASE TYPE / PRINT / EMAIL *Mandatory elds
GENERAL - PERSONAL INFORMATION
Last Name* First* Middle Date of Birth*
Home Address (Street & Number)* City* State* Pin Code*
Address for Communication* Home Telephone Mobile*
Email*
Father's Name*
Mother's Maiden Surname*
Friends or Relatives employed by this Hospital
POSITION DESIRED
(First Choice)* (Second Choice) Previous Pay Scale #
Date available for work* Full Time Part Time
How did you come to know about this job
If Others Please Specify
Website Walk in Advertisement Other
Do you Require Accommodation Provided by the Hospital Yes No
EDUCATION AND QUALIFICATIONS*
Name and Location of the Institution Course / Degree Major Field of Study
College or
University
Graduate School
Other Qualications
BCLS for Healthcare Providers Yes No
# Proof to be furnished
MISCELLANEOUS SKILLS OR ACTIVITIES
List special language skills, scholarships or other signicant activities.
MEMBERSHIP IN PROFESSIONAL ORGANIZATIONS
List the details below
REFERENCES (Other than relatives)*
Give Two References who have known you during the Past One or More years.
Name Position Address (Include City / State) Contact No. & Email
PRESENT EMPLOYMENT*
May we contact your present employer Yes No
Organisation Name From To
Street City PIN Code Telephone No.
Title / Position Supervisor
Duties and Responsibilities?
What did you like most about the work?
What did you like least?
Reason for leaving
PAST EMPLOYMENT
List the past employment details starting from the recent employment as the rst one.
May we contact your past employer Yes No
Organisation Name From To
Street City PIN Code Telephone No.
Title / Position Supervisor
Duties and Responsibilities?
Organisation Name From To
Street City PIN Code Telephone No.
Title / Position Supervisor
Duties and Responsibilities?
SECURITY / RIGHT TO WORK*
Do you have the legal right to work and be employed in the Republic of India? Proof of
identity and legal authority to work in India. (Passport, Aadhaar, PAN Card or Voter ID Yes No
copy to be attached)
Have you ever been convicted of a crime? Yes No
If yes, briey describe the nature of crime(s), the date and place of conviction(s), and the legal disposition
of the case(s).
The Hospital will not deny employment to any applicant solely because he or she has been convicted of a
crime. Each case will be evaluated based on it's own facts and merits.
If you are seeking a position with regular access to patients, have you ever been accused / arrested for a sex-
related offense?
Yes No
If you are seeking a position that would present you with access to drugs and medications, have you ever
been arrested for any drug related offense?
Yes No
If you answered yes to either of the two questions above, please explain the date of the arrest, the facts
involved, and the court, if any, in which the matter was resolved.
OTHER INFORMATION
Please indicate additional information relevant to your application which may be helpful to us.
DECLARATION
I hereby certify that the information contained in this application form is true and correct to the best of
my knowledge and agree to have any of the statements checked by the Hospital unless I have indicated to
the contrary. I authorize the references listed above, as well as all other individuals whom the Hospital
contacts, to provide the Hospital any and all information concerning my previous employment and any other
pertinent information that they may have. Further, I release all parties and persons from any and all liability
for any damages that may result from furnishing such information to the Hospital as well as from any use or
disclosure of such information by the Hospital or any of it's agents, employees, or representatives. I
understand that any misrepresentation, falsication, or material omission of information on this application
may result in my failure to receive an offer or, if I am hired, my immediate dismissal from employment.
In consideration of my employment, I agree to conform to the rules and standards of the Hospital. I further
agree that, unless modied by the rules and regulations as stipulated from time to time by the management
of the Hospital, my employment, compensation, and benets cannot be modied or terminated without
cause, and can be done with sufcient notice stipulated by the Hospital management at anytime, either at
my option or at the option of the Hospital. I understand that no employee or representative of the Hospital,
other than its authorized personnel, has the authority to enter into any agreement for employment for any
specied period of time, or to make any express or implied agreement contrary to the foregoing. Further, the
Hospital may not alter the at-will nature of the employment relationship or enter into any employment
agreement for a specied time unless the authorized personnel and I or my representative both sign a
written agreement that clearly and expressly specied the intent to do so. I agree that this shall constitute a
nal and fully binding integrated agreement with respect to the at-will nature of my employment
relationship and that there are no oral or collateral agreements regarding this issue.
I also understand that all offers of employment are conditioned on: (1) the Hospital's receipt of satisfactory
responses to reference requests and the provision of satisfactory proof of an applicant's identity and legal
authority to work in India; (2) applicant's satisfactory completion of a post-offer medical examination and
occupational health screening; (3) applicant's agreement to abide by and execution of acknowledgment of
the Hospital's employee handbook and employment policies
I fully concur and consent to the above statement*
Date Applicant’s Signature
Print Name
