Community Hospital Long Beach (CHLB) – Job Interest Form

Question Title

* 1. Contact Information

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number

Question Title

* 2. Did you previously work for CHLB?

Yes

No

Question Title

* 3. What was your layoff date?

Date / Time

Date

Question Title

* 4. What were the dates that you were employed at Community Hospital?

Start Date

Date

End Date

Date

Question Title

* 5. What department and/or unit did you work in?

Question Title

* 6. What was your job title/occupation?

Question Title

* 7. Who was your supervisor and/or manager?