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If contacted and considered to be a potentially qualified applicant, a comprehensive Application for Employement must be completed and signed.

It is a Medical Centers policy to hire employees who are drug free and tobacco free. Any applicant who declines to provide a specimen for drug/tobacco testing will not be considered further for employment.

I understand that the facility reserves the right to require its employees to submit to blood tests, urinalyses, or other screenings for alcohol, drugs, or tobacco products, 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 or other screening, when requested to do so, may result in termination of my employment.

Compliance with this facility's Substance Abuse policies (alcohol, drugs, and tobacco products) is a condition of employment. This hospital requires that every newly hired employee be free of alcohol, drug abuse, and tobacco products. Each offer of employment is contingent upon successfully completing a urinalysis test/screen for alcohol, drugs, and tobacco products in accordance with hospital policy. Continued employment is also contingent upon compliance with the hospital's Alcohol, Drug Abuse, and Tobacco Products Policy. This institution follows the "fair employment practice code" and there is no discrimination in the hiring of individuals based on sex, race, religion, age or physical or mental handicap unrelated to ability to perform the work required.

Please Note: A willful misrepresentation or statement concerning tobacco use on the application for employment shall be deemed grounds for dismissal, if the Medical Center is informed during employment that the employee/applicant has not been truthful.

Personal Information

All fields are required
Today's Date: September 9, 2010
First Name:
Middle Initial:
Last Name:
Social Security Number:
Present Address:
City:
State: Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Oregon Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip: (5 digit zip)
Country:
Home Phone Number: (Include Area Code: e.g. 123-456-7890)
Email Address:

If you cannot be reached at the above number where may we contact you?

Name of Person:
Relationship:
Phone Number: (Include Area Code: e.g. 123-456-7890)
Emergency Number: (Include Area Code: e.g. 123-456-7890)

If your former employment references or education records are under a name other than listed above please indicate: (First Name, Last Name, Maiden Name)

Please share your long range occupational and/or educational goals:

Dates available
to begin work:
Can you work overtime if required? (Yes or No) Yes No
Are you 18 years of age or older? (Yes or No) Yes No
How did you learn of this opening?
Are you employed now? (Yes or No) Yes No
May we contact your present employer? (Yes or No) Yes No
After job offer? (Yes or No) Yes No
Additional Comments:

Have you ever been involuntarily discharged from a job? (Yes or No) Yes No
If yes, please explain and provide us with dates:
Have you ever been convicted of any criminal offense other than traffic violations? (Yes or No) Yes No

NOTE: A conviction will not necessarily bar you from employment…

If yes, explain nature of offense and date of conviction in detail:

Were you previously employed by us? (Yes or No) Yes No
If yes when?
What position and/or department?
Please list any friends or relatives presently working for us and their relationship to you:

Employment Desired

Clinical Positions Only:

Primary Position Applied For:
Please list any specialized training you have received for the above position:
Shift Desired:
Salary Expectations:
Full Time? (Yes or No) Yes No
Part Time? (Yes or No) Yes No
PRN? (Yes or No) Yes No
Temporary Assignment:

Secretarial, Industrial, Other Positions Only:

Primary Position Applied For:
Please list any specialized training you have received for the above position:
Shift Desired:
Salary Expectations:
Full Time? (Yes or No) Yes No
Part Time? (Yes or No) Yes No
PRN? (Yes or No) Yes No
Temporary Assignment:

Professional Licenses and/or Certifications

Type:
Organization or State Issued:
Date Issued:
Number:
Type:
Organization or State Issued:
Date Issued:
Number:
Type:
Organization or State Issued:
Date Issued:
Number:

Record of Education, Special Skills, Training, Equipment

List the Highest Grade You Have Completed:

School 1:

School Name:
School Address:
School City:
School State: Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Oregon Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
School Zip: (5 digit zip)
Course(s) Taken:
Year(s) Completed:
Diplomas, Certifications, Degrees, Other:

School 2:

School Name:
School Address:
School City:
School State: Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Oregon Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
School Zip: (5 digit zip)
Course(s) Taken:
Year(s) Completed:
Diplomas, Certifications, Degrees, Other:

School 3:

School Name:
School Address:
School City:
School State: Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Oregon Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
School Zip: (5 digit zip)
Course(s) Taken:
Year(s) Completed:
Diplomas, Certifications, Degrees, Other:

School 4:

School Name:
School Address:
School City:
School State: Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Oregon Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
School Zip: (5 digit zip)
Course(s) Taken:
Year(s) Completed:
Diplomas, Certifications, Degrees, Other:

School 5:

School Name:
School Address:
School City:
School State: Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Oregon Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
School Zip: (5 digit zip)
Course(s) Taken:
Year(s) Completed:
Diplomas, Certifications, Degrees, Other:

List any Scholastic Honors you have received:
Extracurricular activities while in school:
List any memberships to professional organizations:
Other Honors Received, Voluntary or Community Services:

Your Present and Previous Employment Record

List Your Employment Record Beginning with the Most Recent and Descending

Employer 1:

Name of Employer:
Address:
City:
State: Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Oregon Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip: (5 digit zip)
Phone: (Include Area Code: e.g. 123-456-7890)
Supervisor's Name:
Dates Employed:
Salary Range:
Position, Duties, Type of Work:
Reason For Leaving:

Employer 2:

Name of Employer:
Address:
City:
State: Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Oregon Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip: (5 digit zip)
Phone: (Include Area Code: e.g. 123-456-7890)
Supervisor's Name:
Dates Employed:
Salary Range:
Position, Duties, Type of Work:
Reason For Leaving:

Employer 3:

Name of Employer:
Address:
City:
State: Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Oregon Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip: (5 digit zip)
Phone: (Include Area Code: e.g. 123-456-7890)
Supervisor's Name:
Dates Employed:
Salary Range:
Position, Duties, Type of Work:
Reason For Leaving:

Employer 4:

Name of Employer:
Address:
City:
State: Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Oregon Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip: (5 digit zip)
Phone: (Include Area Code: e.g. 123-456-7890)
Supervisor's Name:
Dates Employed:
Salary Range:
Position, Duties, Type of Work:
Reason For Leaving:

Employer 5:

Name of Employer:
Address:
City:
State: Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Oregon Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip: (5 digit zip)
Phone: (Include Area Code: e.g. 123-456-7890)
Supervisor's Name:
Dates Employed:
Salary Range:
Position, Duties, Type of Work:
Reason For Leaving:

Please explain all periods of unemployment:

Personal References

Please list three (3) personal references, not former employers or relatives you have known at least one year, including their name, occupation, address and phone number.

Reference 1:

First & Last Name:
Street: Address:
City:
State: Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Oregon Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip: (5 digit zip)
Phone: (Include Area Code: e.g. 123-456-7890)
Occupation:

Reference 2:

First & Last Name:
Street: Address:
City:
State: Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Oregon Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip: (5 digit zip)
Phone: (Include Area Code: e.g. 123-456-7890)
Occupation:

Reference 3:

First & Last Name:
Street: Address:
City:
State: Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Oregon Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip: (5 digit zip)
Phone: (Include Area Code: e.g. 123-456-7890)
Occupation:

Please read the following paragraphs in their entirety. You must agree with these terms before you can submit your application.

The facts set forth in my application for employment are true and complete. I understand that, if employed, false, misleading or incomplete statements on my application may result in immediate dismissal. I further understand that, if employed, my employment is at-will for an indefinite period and may be terminated at any time by the Medical Center or myself, with or without notice and with or without cause.

I understand that if offered employment, I will complete an employee health survey, which includes a pre-employment drug screen and determines if the essential functions can or cannot be performed. Employment is conditional until the result of the drug screen is reported drug and alcohol free.

I voluntarily give this institution the right to make a thorough investigation of my past employment and activities and agree to cooperate in such an investigation. I authorize my former employers to release information pertaining to work record, work habits and work performance while in their employ. They are hereby released from any and all liability as a result of providing such information to the Medical Center.

I further understand that the institution follows the "fair employment practice code" and there is no discrimination in the hiring of individuals based on sex, race, religion, age or physical or mental handicap unrelated to ability to perform the work required.

I agree to these terms