Application for Employment   HR7940 Rev. 07/02
It is the policy of this facility to provide equal opportunity to persons regardless of race, religion, age, gender, disability or other classification in accordance with federal, state and local statues, regulations and ordinances.
Date: This application to be active for how many days?:   Applicant Name (Please give complete name): Are you at least 18 years old? Yes     No   Social Security No: Home Phone: Present Address: (Include City, State, Zip Code) Previous Address: (If at Present Address Less Than 12 Months): Current Open Position(s) for which you are applying: Type of Position: Per Diem     Full Time     Part Time     Pool     PRN     Temporary     Shift: Day     Evening     Weekend     Night     Rotation     Salary Requirement: Are you willing to travel? Yes     No   Are you willing to relocate? Yes     No   Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours? Yes     No   If overtime work is required periodically, does this pose a problem for you? Yes     No   Date Available for Work: Are You Legally Authorized to Work in the U.S.? Yes     No   Have you ever worked in this, or any other HMA facility? Yes     No   If yes, what facility?: Are you related to another facility employee? Yes     No   How did you learn about this position?:   State Employment Commission   Agency   Job Listing   Current Employee   Ad   School   Job Line   Internet Other:   Are you able to perform the essential, job related functions of the position for which you are applying with or without accommodations? Yes     No   Describe any accomodations necessary:   Have you been convicted of a crime and/or released from confinement following a conviction for any criminal offense? Yes     No   Arrest or changes that have been expunged need not be disclosed. If yes, give date, place and nature of each such conviction:   Are you presently charged with any violation of the law? Yes     No   If yes, please give date, place and nature of each such charge:   Are you currently excluded from participation in any federally funded healthcare program-including Medicare and Medicaid-and are you aware of any potential exclusion from a federally funded health program? Yes     No   Educational History Type of School Name of School, City, State Check Last Year Attended in School Degree or Certificate High School/GED 9th     10th     11th     12th   Graduated?   Yes     No   College 1     2     3     4   Graduated?   Yes     No   College 1     2     3     4   Graduated?   Yes     No   Graduate School 1     2     3     4   Graduated?   Yes     No   Other From (Year) To (Year): Other From (Year) To (Year): List any professional licenses, registration or certification you possess (Include Drivers License, if applicable) Type State Issued Expiration Date Number Clerical or other skills applicable to the position for which you are applying.   Typing   Words Per Minute:     PBX     Proficient in Software     Business Machines and/or Equipment You Can Operate     Other   Employment History Please provide a minimum of the most recent 10 years of employment history including any period of unemployment. Current or Most Recent Employer/Company:   From (Month/Year):       Until (Month/Year):   Phone Number:   Immediate Supervisor:   Salary:   Address:   Name While Employed:   Your Title:   Other Reference:   Nature of Duties:   Reason for Leaving:   May we contact them:   Yes     No   First Previous Employer/Company:   From (Month/Year):       Until (Month/Year):   Phone Number:   Immediate Supervisor:   Salary:   Address:   Name While Employed:   Your Title:   Other Reference:   Nature of Duties:   Reason for Leaving:   May we contact them:   Yes     No   Second Previous Employer/Company:   From (Month/Year):       Until (Month/Year):   Phone Number:   Immediate Supervisor:   Salary:   Address:   Name While Employed:   Your Title:   Other Reference:   Nature of Duties:   Reason for Leaving:   May we contact them:   Yes     No   Third Previous Employer/Company:   From (Month/Year):       Until (Month/Year):   Phone Number:   Immediate Supervisor:   Salary:   Address:   Name While Employed:   Your Title:   Other Reference:   Nature of Duties:   Reason for Leaving:   May we contact them:   Yes     No   Professional References (Other Than Relatives) Give two references who have good knowledge of your work. Name Position Address (inc. city/state) Phone: Work/Home Number of Years Known Please Review: Submission of this electronic job application indicates that you have read and understood the following: 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 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. I UNDERSTAND AND AGREE THAT ANY EMPLOYEE HANDBOOK WHICH I MAY RECEIVE WILL NOT CONSTITUTE AN EMPLOYMENT CONTRACT, BUT WILL BE MERELY A GRATUITOUS STATEMENT OF FACILITY POLICIES. 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 hospital's 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. Release: I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also 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 any and 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 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 & Medical Leave Act, state civil rights acts, the law of contract and the law of tort.