This hospital is an equal opportunity employer. Federal and State laws prohibit discrimination in employment practices based on race, color, religion, sex, age, disability, or national origin. No question on this application is asked for the purpose of limiting or excluding any applicant's consideration for employment because of his or her race, color, religion, sex, age, disability or national origin.
CURRENT OPENINGS
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EMPLOYMENT APPLICATION
Education
Name and Location of School
Course of Study
No. of Years Completed
Did you graduate?
Degree or Diploma
High School
College
Other
License / Certification / Skill / Experience
See sample list below. Please specify all experience and skills, which pertain to the position(s) you are applying.
Professional License
Type
State Issued
Date
Number
Type
State Issued
Date
Number
Cert. Name
No.
Exp. Date
Cert. Name
No.
Exp. Date
Clinical Experience
Duration
Clinical Experience
Duration
Clinical Experience
Duration
Other, please list:
Examples
Certified in ACLS / CPR / NALS / PALS
Certified as Childbirth Educator
Certified in Critical Care Nursing
Certified Medical Staff Recruiter
Certified as Enter. Ther. Nurse
Certified in Emergency Nursing
Certification for Gerontol. Nursing
Certified in IV Therapy
Certified in Nursing Administration
Certified Orthopaedic Nurse
Cert. Quality Assess/Assur Nurse
Clerical Experience: Account Payable / Receivable, Admissions, Billing, Payroll, Stock Clerk, Receptionist
Clinical Experience
Associates Degree
Bach / Master of Arts/Science/Nursing Degree
Bach / Master Degree in Social Wk
Masters in Business Administration
Doctorate Degree
Electrical
HVAC
Plumbing
Instructor for ALCS / CPR / NALS / PALS
ICD-9-CM Coding
Knows Sign Language
Machinery: Adding, Calculator, Dictaphone, Copier, Computer, Typewriter - WPM
Managed Care Experience
Medical Terminology
Medical Transcriptionist
Notary Public
Shorthand WPM
Speaks a Foreign Language
Spreadsheet software
Word Processing software
Military
Complete this section if you served in the US Armed Forces
Branch of Service:
Describe your duties and/or special training relevant to the position(s) for which you are applying.
References
List three individuals whom are not relatives or previous employers. Please provide addresses as written references are mailed.
Name
Occupation
Phone Number
Mailing Address
City
State/ZIP
Name
Occupation
Phone Number
Mailing Address
City
State/ZIP
Name
Occupation
Phone Number
Mailing Address
City
State/ZIP
Have you ever been convicted of any violation other than a misdemeanor or summary offense which is relative to the job(s) for which you are applying?
If yes, describe in full:
Employment
Give a complete record of all employment full or part time Begin with the most recent employment.
Employer's Name
Telephone
Street
City
State
ZIP
Employed From:
To:
Position Held:
Name of Supervisor:
Last Salary:
Duties:
Reason for Leaving:
Employer's Name
Telephone
Street
City
State
ZIP
Employed From:
To:
Position Held:
Name of Supervisor:
Last Salary:
Duties:
Reason for Leaving:
Employer's Name
Telephone
Street
City
State
ZIP
Employed From:
To:
Position Held:
Name of Supervisor:
Last Salary:
Duties:
Reason for Leaving:
Employer's Name
Telephone
Street
City
State
ZIP
Employed From:
To:
Position Held:
Name of Supervisor:
Last Salary:
Duties:
Reason for Leaving:
May we contact the Employers listed above?
If not, please indicate which one(s):
May we contact your current Employer?
Applicant: Please read statement, fill in your name and date to indicate your understanding.
I hereby certify that the foregoing statements are true and correct to the best of my knowledge and belief, and hereby grant the Hospital permission to verify such answers and investigate all references. I understand that any false statements on this application may be considered sufficient cause for rejection of this application or for dismissal if such false information is discovered subsequent to my employment. I authorize the employers, schools, or persons named above to give any information regarding my previous employment, character, general reputation and personal characteristics, together with any information they have regarding me whether or not it is in their records. I understand that under the Federal Fair Credit Reporting Act, I have the right to make written requests within a reasonable period of time for a complete and accurate disclosure by the Hospital of the nature and scope of any investigation requested by the Hospital of a consumer reporting agency. If this application for employment is denied either wholly or partly because of information contained in a consumer report from consumer reporting agency, the applicant understands that the Hospital shall so advise him or her and shall supply the name and address of the consumer reporting agency making the report. I hereby release said agency, employers, schools, or persons from all liability for any damage for issuing this information. In addition, if accepted for employment, I hereby agree to abide by the rules and regulations of the Hospital.
Nothing contained in this employment application or in the granting of an employment interview is intended to create an employment contract between the Hospital and the applicant. In the event that an employer-employee relationship is established, it is understood that my employment with the Hospital does not, in any means, constitute a contract. I can be terminated at any time with no specific duration, with or without cause, and that by accepting employment, I agree with this condition of employment. I further understand that any modification of this arrangement must be reduced to writing and signed by me and an authorized reprentative of the Hospital.
