HEALTHCARE DESIGNED WITH   YOU   IN   MIND

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Employment Application


In order to be considered for employment, please fill out the following form completely.
Personal Information
Last Name First Middle
Present Address City State Zip
Permanent Address City State Zip
Home Telephone Number Contact Telephone Number Email Address(optional)
Best Time To Contact You? Date Available For Work:
Check All You Would Consider Working: Would You Consider Working:
Full Time/Regular Weekends & Holidays Yes No
Full Time/Temporary Rotating Shifts Yes No
Part Time/Regular On Call Yes No
Part Time/Temporary Any Shift Yes No
Shift Availabality(check all that apply):
Days Evenings Nights
*Position Applied For: Salary Desired:
How Did You Learn About This Position
Relatives OR Freinds Employed In This Facility? YES NO
Name: Dept: Relationship:
Have You Ever Been Employed By This Facility? Yes No
When?
Are You 18 Yrs Of Age Or Older? Yes No
Are You A U.S. Citizen Or An Alien Legally Authorized To Work In The United States: Yes No
Long Range Occupational Goals
Have You Ever Been Convicted Of ,Or Plead Guilty To,A Crime Other Than A Misdemeanor Traffic Voilation? Yes No
If Yes, Which State(S), And Explain: (You are not required to disclose any SEALED or EXPUNGED criminal records.)
Have You Ever Been Involved In The Substantiated Abuse Or Neglect Of Children Or Adults Under The Laws Of This Or Any Other State Of The United States? Yes No
If Yes, Which State(S), And Explain:
Have You Been Sanctioned, Cited, Reported, Or Excluded From Participation In Medicare, Medicaid, Or Any Other Healthcare Related Law or Regulation? Yes No
If Yes, Explain:
If your answer is "yes" to any of the above, you will not be automatically disqualified from employment consideration, except as required by state or federal law.

Education
Name And Address Of School Course Of Study Last Year Completed Did You Graduate? Diploma Or Degree
High YES
NO
College: Yes
No
College: Yes
No
 
Other Business College or Special Courses: (Include Special Military Training, Post Graduate and Nursing)
Area(S) Of Specialization Or Major Interest: List Office Skills Including Computer/Software Experience:
List Health Care, Business, Or Industrial Equipment Operated: Word Processing: (Approx. WPM)
Professional Licenses
Currently Licensed Eligible For License License Or Registration Ever
Suspended, Revoked Or On Probation?
Currently Registerd Eligible For Registration Yes No
Type: State If Yes, Explain:
No Date

Currently Licensed Eligible For License License Or Registration Ever
Suspended, Revoked Or On Probation?
Currently Registered Eligible For Registration Yes No
Type: State If Yes, Explain:
No Date
Professional Certifications
Currently Certified
Eligible For Certification
Type
State:
Date:
Currently Certified
Eligible For Certification
Type
State:
Date:
Briefly Describe Duties And Skills
Acquired Through Military Or Volunteer Service

Provide Information Regarding Previous Employment Beginning With Most Recent Employer.
First Employer
Employer Name: Supervisor Name Telephone Number:
Address
Job Title: Employed From Employed To
Starting Salary Final Salary
Reason For Leaving
Duties
May We Contact Your Current Employer?
Yes No
Second Employer
Name of Employer: Last Supervisor: Telephone Number:
Address
Postin Held Employed From Employed To
Starting Salary Final Salary
Reason For Leaving
Duties
Third Employer
Name of Employer: Last Supervisor: Telephone Number:
Address
Postin Held Employed From Employed To
Starting Salary Final Salary
Reason For Leaving
Duties
Fourth Employer
Name of Employer: Last Supervisor: Telephone Number:
Address
Postin Held Employed From Employed To
Starting Salary Final Salary
Reason For Leaving
Duties
 
Please Identify And Explain Any Gaps In Employment Longer Than Three (3) Months:

Language
Language Skills - Do Not Complete Unless Requested
Language
Do You? Speak Fair
Good
Fluent
Read Fair
Good
Fluent
Write Fair
Good
Fluent
 
Language
Do You? Speak Fair
Good
Fluent
Read Fair
Good
Fluent
Write Fair
Good
Fluent

References
List At Least Three (3) Professionals / Work / School References Who Are Not Relatives Or Personal Acquaintances:
 
*Name And Relationship *Title *Company Name And Address *Telephone

Applicant Authorization
Carefully Read This Section Prior To Providing Signature Below

I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete. I understand that any false or misleading representa-
tions or omissions made on the application or during the hiring process may disqualify me from further consideration for employment and may result in discharge even if
discovered at a later date.

I understand that employment may be conditioned upon successfully passing a medical examination and that I may be required to satisfactorily complete a drug screening as
a condition of employment.

I hereby authorize persons, schools, my current employer (if applicable) and previous employers and other organizations to provide this facility and its affiliates with any
request- ed information regarding my application or suitability for employment, and I completely release all such persons or entities from any and all liability related to the providing
or use of such information.

I understand that my employment is at-will which means that I may terminate the employment relationship at any time and for any reason with or without notice, and that the
facil- ity has the same right. I understand that no one has the authority to enter into any agreement contrary to the preceding sentence, except for a written agreement signed by an
admin- istrative representative of this facility and notarized.

*Applicant Signature *Date:

Attach ResumeResume Format
*Verification Code
Type In Number Letter