Secure Application for Employment
It is the policy of this facility to provide equal opportunity to persons regardless of race, religion, age, gender, disability or any other classification in accordance with federal, state and local statutes, regulations and ordinances.
ALL FIELDS MARKED WITH * ARE REQUIRED FIELDS.
Personal Information
*Last Name:
*First Name:
Middle :
Date of Application
Jul-31-2010
*Home Phone:
Current Email:
Cell Phone:
*Current Address:
*Current City:
*Current State:
*Current Zip:
*Have you ever been employed here before? If yes, give date.
yesno
*Are you currently employed?
yesno
*Are you related to another SMITH Northview Hospital Employee? If Yes, please list their name and the relationship:
yesno
*Are you legally authorized to work in the USA? (Proof of Citizenship or immigration status will be required upon employment.)
yesno
*Do you have adequate means of transportation?
yesno
*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?
yesno
*Note: Answering "Yes" to any of these questions may not necessarily disqualify you from the position desired. Each action and explanation will be weighted / considered in relationship to the position for which you are applying.
*Have you ever been convicted of a crime, had adjudication of a crime withheld, or pled nolo contendere to a crime? If yes, please state the circumstances with regard to each.

yesno
*Have you been arrested for any crime that had not been adjudicated? If yes, please state the circumstances and current status of each arrest.

yesno
*Have you ever been a defendant in a civil action for intentional tort? Intentional tort commonly refers to examples, such as assault, battery, and false imprisonment.

yesno
Employment Desired
*Position(s) applied for:
How did you learn about this position?
Shift?

Type of Position:
Pay Requirement:
$  
On what date would you be available to begin work?
 /  / 
Qualifications
List any professional licenses, registration or certification you possess(CPR, ACLS, etc.) Include Type, State Issued, Expiration Date and Number. Indicate if any licenses have been revoked, suspended or placed on probation. Also indicate if you are ineligible to become licensed or certified in your field. Please explain.
Clerical or other skills applicable to the position for which you are applying.
Typing WPM:
Software proficient in:

Business machines and / or equipment you can operate

Other
Educational History
Type of School
School Information
Highest Level Completed
High School
Name:

City:

State:
910 1112
Graduated/GED?
yesno
Diploma/Certificate:
College
Name:

City:

State:
12   3  4
Graduated?
yesno
Degree:
College
Name:

City:

State:
12   3  4
Graduated?
yesno
Degree:
Graduate
School
Name:

City:

State:
12   3  4
Graduated?
yesno
Degree:
Honors Received: State any professional, (Trade, Business, or Civil Activities), or Academic Honor that you have received or been involved in.
Describe Specialized Training, Apprenticeship, Skills and Extra-Curricular Activities.
Work History
Current or Most Recent Employment
Name while Employed
Employer Name
Start Date
 /  / 
End Date
 /  / 
Address
Start Salary
End Salary
Essential job functions of final position
City
State
Zip
Phone Number
Fax Number
Supervisor(s)

Job Title(s)
PRNFull Time
Part Time
 
Reason(s) for leaving
Would you like to list another job
yesno
Professional References
Give name, address and telephone number, relationship & years known for 2 professional references who are not related to you.
Name
Position
Address
(include City/State)
Phone
Number of
years known
Please Review and Acknowledge that You Understand the Following:
In making application for employment:

  •   I certify 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 a 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 hospitals 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 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 any licensure status and my licensure history.
*I have read and understand these conditions of employment.
Yes

*Applicant's Full Name
Date Prepared:
Jul-31-2010
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