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 OK Question Title * 2. Did you previously work for CHLB? Yes No OK Question Title * 3. What was your layoff date? Date / Time Date OK Question Title * 4. What were the dates that you were employed at Community Hospital? Start Date Date End Date Date OK Question Title * 5. What department and/or unit did you work in? OK Question Title * 6. What was your job title/occupation? OK Question Title * 7. Who was your supervisor and/or manager? OK NEXT