1

DREAM HOSPITAL, INC.

Employment Application
Applicant Information
Full Name: Ramirez Vania A Date: May 27 2014
Last First M.I.

Address: 5501 N. Cypress
Street Address Apartment/Unit #

Pharr Tx 78577
City State ZIP Code

Phone: (956)802-1021 Email vaniaramirez26@gmail.com

Date Available: Social Security No.: Desired Salary: $

Position Applied for: Pediatric surgeon

Are you a citizen of the United States?
YES

NO
If no, are you authorized to work in the U.S.?
YES

NO


Have you ever worked for this company?
YES

NO
If yes, when?

Have you ever been convicted of a felony?
YES

NO


If yes, explain:
Education
High School: Edinburg High School Address:

From: 2011 To: 2015 Did you graduate?
YES

NO
Diploma::

College: Address:

From: To: Did you graduate?
YES

NO
Degree:

Other: Address:

From: To: Did you graduate?
YES

NO
Degree:
References
Please list three professional references.
Full Name: Dayana Carrillo Relationship: Co worker
Company: Dayanas Family Clinic Phone: (956)456-9876
Address: 711 N. Burger St.

2
Full Name: Lyana Flores Relationship: friend
Company: Rainbow Pediatrics Phone: (956)581-9999
Address: 681 S. Burrito Lane

Full Name: Kristal Espinoza Relationship: friend
Company: Ks Home Health Care Phone: (956)666-1666
Address: 9999 N. Taco Rd
Previous Employment
Company: Phone:
Address: Supervisor:

Job Title: Starting Salary: $ Ending Salary: $

Responsibilities:

From: To: Reason for Leaving:

May we contact your previous supervisor for a reference?
YES

NO




Company: Phone:
Address: Supervisor:

Job Title: Starting Salary: $ Ending Salary: $

Responsibilities:

From: To: Reason for Leaving:

May we contact your previous supervisor for a reference?
YES

NO




Company: Phone:
Address: Supervisor:

Job Title: Starting Salary: $ Ending Salary: $

Responsibilities:

From: To: Reason for Leaving:

May we contact your previous supervisor for a reference?
YES

NO

3
Military Service
Branch: From: To:

Rank at Discharge: Type of Discharge:

If other than honorable, explain:
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or
interview may result in my release.
Signature:
Vania Ramirez
Date: May/27/14