Name
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
*
Date Available
*
MM
DD
YYYY
Social Security No
*
Position Applied for
*
Are you a citizen of the United States?
*
Yes
No
If no, are you authorized to work in the U.S.?
Yes
No
Are you willing to relocate?
*
Yes
No
If yes, when?
MM
DD
YYYY
Do you have adequate means of transportation to get to work?
*
Yes
No
Are you related to another facility employee?
Yes
No
Are you currently excluded from participation in any federally funded healthcare program--- including Medicare and Medicaid---and are you aware of any potential exclusions from a federally funded health program?
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
If yes, please explain:
High School
*
High School Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
From:
*
To:
*
Did you graduate?
*
Yes
No
Diploma:
*
College:
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
From:
To:
Did you graduate?
Yes
No
Degree:
College:
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
From:
*
MM
DD
YYYY
To:
MM
DD
YYYY
Did you graduate?
Yes
No
Degree:
Company:
*
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Supervisor:
*
Job Title:
*
Responsibilities:
*
From
*
MM
DD
YYYY
To:
*
MM
DD
YYYY
Reasons for Leaving:
*
May we contact your previous supervisor for a reference?
*
Yes
No
Company
*
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Supervisor:
*
Job Title:
*
Responsibilities:
*
From:
*
MM
DD
YYYY
To:
*
MM
DD
YYYY
Reason for Leaving:
*
May we contact your previous supervisor for a reference?
*
Yes
No
Company:
*
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Supervisor:
*
Job Title:
*
Responsibilities:
*
From:
*
MM
DD
YYYY
To:
*
MM
DD
YYYY
Reason for Leaving:
*
May we contact your previous supervisor for a reference?
*
Yes
No
Full Name:
*
Relationship:
*
Company:
*
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Full Name:
*
Relationship:
*
Company:
*
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Full Name:
*
Relationship:
*
Company:
*
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
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. This facility is an "at will" employer. All employees who do not have a separate written employment contract for a specific, fixed term of employment are employed at the will of the facility for an indefinite period. Employees may resign at any time and may be terminated at any time by the facility, with or without notice, and with or without cause. Nothing contained herein alters or should be relied on as altering this at-will relationship. 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. 4 I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested and 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 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 condition of employment.
*
Signature
Date
MM
DD
YYYY
Race/Ethnicity:
*
Veteran Status: (Please check all that apply)
*I agree that this form may be electronically signed and agree that my typed signature is the same as a
handwritten signature for the purposes of validity, enforceability, and admissibility.
