It is the policy of this facility to provide equal opportunity to persons regardless of race, religion,
age, gender, disability or any other classification in accordance with federal, state and local
statutes, regulations and ordinances.

    First Name Middle, Last Name Email
    Are You At Least 18 Years Old? Last 4-digits of Social Security Number Home Phone And Cell Phone
    Present Address Present City Present ZIP Code
    Previous Address Previous City Previous ZIP Code
    Current Open Position that you are applying: Type of Position:
    Shift:
    Salary Requirement Are you willing to travel? Are you willing to relocate?
    Do you have adequate way of transport to get to work
    on time each day and when called on short notice during normal working hours?

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

    Date Available
    for work?
    Are You Legally Authorized to Work in the U.S.? Have you ever worked in this facility? If yes, what facility?
    Are you able to perform the essential, job related
    functions of the position for which you are applying
    with or without reasonable accommodations?

    Describe any
    accommodations necessary:

    Are you related to
    another facility employee?
    Are you currently excluded from participation in an
    federally funded healthcare program including Medicare
    and Medicaid? Are you aware of any potential exclusion from federally funded health program?


    Are you presently charged with any
    violation of the law?


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

    How did you learn about this position?:
    Other


    Professional Certifications

    Type: State: Date Number Status
    Type: State: Date Number Status


    Language

    Language: Do you speak?
    Do you read?
    Do you write?
    Language: Do you speak?
    Do you read?
    Do you write?


    Armed Services/Volunteer Information

    Did you serve in the U.S. Armed Services? What branch?
    Have you volunteered your time or services? Where?
    Briefly describe duties and skills acquired through
    military or volunteer service (include dates):

    Educational History

    Type of School Name of
    School City, State
    Last Year Attended in
    School
    Graduated/GED? Degree
    or Certificate
    High School
    College
    College
    Graduate School
    Other

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

    Typing (WPM)
    Explanation
    Explanation
    Explanation

    List any professional licenses, registration or certification you possess (Include only the last 4 digits of your 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

    From (MM/YYYY): To (MM/YYYY): Company Phone No. Immediate Supervisor
    Salary ($): Address: Name while employed May we contact them?
    Job Title: Job Type # Hrs/Week: Reason For Leaving Nature of Duties
    1st Previous

    From (MM/YYYY): To (MM/YYYY): Company Phone No. Immediate Supervisor
    Salary ($): Address: Name while employed May we contact them?
    Job Title: Job Type # Hrs/Week: Reason For Leaving Nature of Duties
    2st Previous

    From (MM/YYYY): To (MM/YYYY): Company Phone No. Immediate Supervisor
    Salary ($): Address: Name while employed May we contact them?
    Job Title: Job Type # Hrs/Week: Reason For Leaving Nature of Duties
    3rd Previous

    From (MM/YYYY): To (MM/YYYY): Company Phone No. Immediate Supervisor
    Salary ($): Address: Name while employed May we contact them?
    Job Title: Job Type # Hrs/Week: Reason For Leaving Nature of Duties

    Professional References (Other than Relatives) Give references who have good knowledge of your work.

    Name Position Address (Include City/State) Phone - Work/Home Number of Years known


    In making application for employment:
    * I certify 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.

    /tr>

    Please Review and Acknowledge That You Understand The Following.

    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 hospital's 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 agree that I will settle any and all claims, disputes or controversies arising out of or relating to my application for employment, employment or termination of employment with the employer exclusively by final and binding arbitration and before a neutral Arbitrator and in accordance with the rules and procedures for employment disputes adopted by the employer. Such claims shall include those that could be brought in a court of law under any applicable federal, state or local statutory or common law, such as the Age Discrimination in Employment Act, Title VII of the Civil Rights Act of 1964, as amended, including the amendments of the Civil Rights Act of 1991, the Americans with Disabilities Act, the Family and Medical Leave Act, state civil rights acts, the law of contract and the law of tort.


    I have read and understand these conditions of employment. Applicant's full name Date prepared

    Acknowledgement and Authorization

    In considering your application for employment, the facility may conduct a detailed and thorough investigation, which may include but is not limited to criminal record check, interviews, or inquiries of prior employers, coworkers, acquaintances, relatives, or friends.

    Application Addendum

    Last Name First Last 4 Digits of Social Security Number Maiden And/Or Other Name(s) Used
    Last 4 Digits of Driver's License Sex Current Address(street) State
    City State Zip County
    I understand that by checking the following box and typing my name into the name field above, this document is as valid as if I have signed it. Applicant's full name

    1. Have you ever been convicted of a crime, had adjudication of a crime withheld, or pled nolo contendere to a crime? If yes, please state the circumstances with regard to each.
    2. Have you been arrested for any crime that had not been adjudicated? If yes, please state the circumstances and current status of each arrest.
    3. Have you ever committed a crime for which you were not arrested or convicted? If yes, please state the circumstances.
    4. Have you ever been a defendant in a civil action for intentional tort? Intentional tort commonly refers to examples, such as assault, battery, and false imprisonment: If yes, please state the circumstances.
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