Surgical Technologist Training Program Application

Personal Information:

Name *

First

Middle Initial

Last *

Last

Email *

Phone *

Address *

Address

Address Line 1

Address Line 2

City

State/Province

Zip/Postal

Have you ever used another name? *

No

Yes

If YES: *

Education:

High School

Official transcripts must be in sealed envelopes and should be sent directly from the College/University to the Surgical Technologist Training Program: Attn Valerie Rescsanski, Dept. of Perioperative Services, 1 Medical Center Dr. Lebanon, NH 03756.

Institution from which Diploma issued:

Graduated:

Yes

No

GED

Transcripts Requested

Address

Address Line 1

Address Line 2

City

State/Province

Zip/Postal

Country

College / University / Technical School:

List all attended. Click the "Add Another Institution" button below this section to add more institutions.

Institution Name

Address

City

State/Province

Zip/Postal

Country

Dates of Attendance

Degree/Diploma/Class

Major (if applicable)

Transcripts Requested

Awards/honors/etc.

Add Another Institution Remove

Questionnaire:

To help us better know you and further assess your qualifications for this position, please answer the following questions as accurately as possible.

Have you previously been employed by Dartmouth-Hitchcock at any of its locations? If yes, please indicate location and department. *

Yes

No

Location and Department *

If you answer “Yes” to any of the following questions, the D-H Workforce Readiness Institute will reach out to you for additional information.

Have you ever been convicted in any state of any felony, sexual assault, other violent crime, assault, fraud, abuse, neglect or exploitation of any person, that has not been annulled by a court? (Note to Applicant: Convictions which have not been annulled will not necessarily bar you from employment. We will consider factors such as age when the offense occurred, the recentness of the offense, the seriousness and nature of the violation, the nature of the position applied for and any rehabilitation undergone. Failure to disclose a conviction can lead to withdrawal of the employment offer.) *

Yes

No

Have you ever been excluded, suspended, debarred, or otherwise ineligible to participate in the federal health care programs? *

Yes

No

Has any hospital or licensed facility restricted or terminated your professional training, employment or privileges? *

Yes

No

Have you voluntarily resigned or withdrawn from any hospital or licensed facility due to professional misconduct, incompetence or negligence? *

Yes

No

Sponsorship:

I am a Dartmouth-Hitchcock employee applying to the Surgical Technologist Training Program interested in sponsorship in Lebanon, NH as a sponsored Dartmouth-Hitchcock employee: *

Yes

No

I am a current D-H employee in good standing and will have been in my current role for at least 12 months by September 23, 2019 *

Yes

No

I am applying to the Surgical Technologist Training Program interested in sponsorship in Keene, NH. All class and training will take place in Lebanon, NH *

Yes

No

In addition to the application materials for the program, please also submit a sponsorship application essay that demonstrates to the Department of Perioperative Services how your performance and commitment to Dartmouth-Hitchcock demonstrates the value of your sponsorship. One of your reference letters must be from your current supervisor/manager.

I have registered to attend or already attended the

Thank you for your interest in the D-H Surgical Technologist Training Program. We are looking forward to receiving your application and getting to know you through this application process.

Apply via the form below

Personal Information:

Education:

High School

College / University / Technical School:

Questionnaire:

Sponsorship: