Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, or the presence of non-job-related-physical or mental handicap or disability.

Present Address

Permanent Address

It is the employer’s intent to hire only United States citizens and aliens lawfully authorized to work in the United States. All newly hired employees will be required to complete and sign the verification form designated by INS to certify that they are eligible for employment in the United States.

Conviction of a crime does not necessarily disqualify you from consideration for employment.

EDUCATION/LICENSURE/CERTIFICATION

EMPLOYMENT HISTORY OF ALL PREVIOUS EMPLOYERS

This section must be completed in full to be considered for employment Please list name, address and phone number of previous employers with most recent employer first

1.)

2.)

3.)

4.)

REFERENCES

REMARKS

Applicant’s agreement and release of information
Conditions of employment (read carefully)
All offers of employment are contingent upon:
1. A satisfactory physical examination by your physician and at our expense.
2. A satisfactory check of references, supporting transcripts and licensure of registry verification.
3. An employment certification or transferable work permit is required if the applicant is under 18 years of age.
4. A satisfactory pre-placement drug screen.
5. A satisfactory security check.
6. A satisfactory credit check of applicant’s credit history.
Applicant’s Acknowledgement
I certify that the information contained in this application is correct to the best of my knowledge, and understand that falsification of this information is grounds for refusal to hire or, if hired, dismissal at any time. I authorize any of the persons or organizations referenced in this application to give you any and all information concerning my previous employment, education or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application, and release all such parties from all liabilities for any damages that may result from furnishing such information to you. I authorize you to request and receive such information and release all such parties from all liability for any damages that may result from furnishing such information to you. In consideration for my being considered for employment by your hospital, I agree that in the event of employment to conform to the rules and regulations of the hospital and acknowledge that these rules and regulations may be changed, interpreted, withdrawn or added to by your hospital at any time, at the hospital’s sole option, and without any prior notice to me. I further acknowledge that my employment may be terminated, and any offer of employment, or my acceptance of an employment offer, if such is to occur, may be withdrawn, with or without cause, and with or without prior notice, at any time, at the option of the hospital or myself. I understand that no representative of the hospital has any authority to enter into any agreement for employment for any specified period of time or to assure any other personnel action, either prior to commencement of employment or after I have become employed, or to assure any benefits or terms and conditions of employment, or make any agreement contrary to the foregoing. I understand that this application is not and is not intended to be a contract of employment. As part of the procedure for processing this application, I understand and authorize that an investigative report may be made, by the hospital or through an agency. Information for such reports is obtained through personal interviews with third parties such as family members, business associates, financial sources, friends, neighbors or others who might be acquainted with me. Information sought may be related to character, general reputation or personal characteristics. If such an investigation is undertaken, I have the right to obtain a copy of the investigative report furnished to the hospital by making a written request to the hospital or to the agency furnishing the report within a reasonable time from the date of the report.