Job Application

Personal Information

Last Name:

First Name:

Middle Initial:

Are you at least 18 years old?

Home Phone:

Cell Phone:

Email:

Present Address:

Present City:

Present State:

Present Zip Code:

Previous Address:

Previous City:

Previous State:

Previous Zip:

Position Applying For:

Type of Position:

Per Diem

Full Time

Part Time

Pool

PRN

Temporary

Shift:

Day

Evening

Weekend

Night

Rotation

Salary Requirement

Are you willing to travel?

Are you willing to relocate?

Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?

If overtime work is required periodically, does this pose a problem for you?

Date available to work?

Are You Legally Authorized to Work in the U.S.?

Have you ever worked in this or any other facility?

If yes, what facility?

Are you related to another facility employee?

Are you able to perform the essential, job related functions of the position for which you are applying with or without accommodations?

Describe any accommodations necessary:

Have you been convicted of a crime and/or released from confinement following a conviction for any criminal offense?

If yes, give date, place and nature of each such conviction (Arrests or charges that have been expunged need not be disclosed).

Are you presently charged with any violation of the law?

If yes, give date, place and nature of each such event:

Are you currently excluded from participation in any federally funded healthcare program - including Medicare and Medicaid - and are you aware of any potential exclusion from a federally funded health program?

How did you learn about this position?

Educational History

High School

School:

City:

State:

Last Year Attended:

9 10 11 12

Graduated / GED?

Select ... Yes No

College

School:

City:

State:

Last Year Attended:

1 2 3 4

Graduated?

Select ... Yes No

Degree:

College

School:

City:

State:

Last Year Attended:

1 2 3 4

Graduated?

Select ... Yes No

Degree:

Graduate School

School:

City:

State:

Last Year Attended:

1 2 3 4

Graduated?

Select ... Yes No

Degree:

Other

School:

City:

State:

Last Year Attended:

1 2 3 4

Graduated?

Select ... Yes No

Degree:

Other

School:

City:

State:

Last Year Attended:

1 2 3 4

Graduated?

Select ... Yes No

Degree:

Job Skills

Clerical or other skills applicable to the position for which you are applying:

List any professional licenses, registration or certification you possess(Include Driver's License, if applicable) Include Type, State Issued, Expiration Date and Number. Indicate if any licenses have been revoked, suspended or placed on probation. Also indicate if you are ineligible to become licensed or certified in your field. Please explain.

Work History

Current or Most Recent Job

Start (mm/yyyy):

End (mm/yyyy):

Company:

Title:

Nature of Duties:

Salary:

Address:

Phone Number:

Name While Employed:

Immediate Supervisor:

Reason For Leaving:

2nd Previous Job

Start (mm/yyyy):

End (mm/yyyy):

Company:

Title:

Nature of Duties:

Salary:

Address:

Phone Number:

Name While Employed:

Immediate Supervisor:

Reason For Leaving:

3rd Previous Job

Start (mm/yyyy):

End (mm/yyyy):

Company:

Title:

Nature of Duties:

Salary:

Address:

Phone Number:

Name While Employed:

Immediate Supervisor:

Reason For Leaving:

4th Previous Job

Start (mm/yyyy):

End (mm/yyyy):

Company:

Title:

Nature of Duties:

Salary:

Address:

Phone Number:

Name While Employed:

Immediate Supervisor:

Reason For Leaving:

Professional References (Other than Relatives)

Give references who have good knowledge of your work.

Reference #1

Name:

Position:

Address:

Phone:

Number of Years Known:

Reference #2

Name:

Position:

Address:

Phone:

Number of Years Known:

Reference #3

Name:

Position:

Address:

Phone:

Number of Years Known:

Reference #4

Name:

Position:

Address:

Phone:

Number of Years Known:

Legal

Please Review and Acknowledge That You Understand The Following.

In making application for employment:
* I certified that the information in this application is true and complete for all practical purposes. It may be verified by the facility or any affiliate. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the facility or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.

* I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable. If such an investigative report is made, I understand that I will receive notice that such a report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.

* I UNDERSTAND AND AGREE THAT ANY EMPLOYEE HANDBOOK WHICH I MAY RECEIVE WILL NOT CONSTITUTE AN EMPLOYMENT CONTRACT, BUT WILL BE MERELY A GRATUITOUS STATEMENT OF FACILITY POLICIES.

* I understand that the facility reserves the right to require its employees to submit to blood tests or urinalyses for alcohol or drug screens, or to allow inspection of bags (including purses or briefcases) or parcels brought into or taken out of the facility. I understand that refusal to submit to a urinalysis or blood test, when requested to do so, may result in termination of my employment.

* Compliance with this facility's Substance Abuse Policy is a condition of employment. This hospital requires that every newly hired employee be free of alcohol or drug abuse. Each offer of employment is contingent upon successfully completing a urinalysis test/screen for alcohol and drugs in accordance with hospital policy. Continued employment is also contingent upon compliance with the hospitals Alcohol and Drug Abuse Policy.

*I UNDERSTAND AND AGREE THAT IF I AM OFFERED EMPLOYMENT BY THE FACILITY, MY EMPLOYMENT WILL BE FOR NO DEFINITE TERM AND THAT EITHER I, OR THE FACILITY WILL HAVE THE RIGHT TO TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, I ALSO UNDERSTAND THAT THIS STATUS CAN ONLY BE ALTERED BY A WRITTEN CONTRACT OF EMPLOYMENT WHICH IS SPECIFIC AS TO ALL MATERIAL TERMS AND IS SIGNED BY ME AND THE ADMINISTRATOR OF THE FACILITY.

Release:
I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my licensure status and my licensure history.

I have read and understand these conditions of employment:

Applicant's Full Name:

Date Prepared:

By clicking the "Forward to Release Authorization" button below, I agree that all of the preceding questions are answered truthfully and to the best of my abilities.

Your IP address has been recorded and will be kept on record with your application as confirmation of your digital signature and as proof of identity.