All persons should have the opportunity to be considered for employment without regard to their race, color, religion, national origin or ancestry, handicap or disability, sex, marital status, obligation to serve in the armed forces of the United States, citizenship or other characteristic protected by applicable federal or state law.
Date *
Position Applied For: *
Are You Applying for: Full TimePart TimeTemporaryPRNOther
PERSONAL INFORMATION
Name:* *Address:* *
City* * State:*
Day or Night Telephone Number: *
MISCELLANOUS:
Are you either a U.S. citizen or an alien who has the legal right to work in the job for which you are applying? Yes No
Are you currently excluded, suspended, debarred or otherwise ineligible to participate in the Federal health care programs, or have you been convicted of a criminal offense related to the provision of health care items or services but not yet been excluded, debarred, or otherwise declared ineligible? Yes No
Are you 18 or older? Yes No
Have you ever been convicted of any crime other than a minor traffic violation? A criminal conviction will not necessariily be a bar to employment. Please describe the nature of the crime and you rehabilitation. If yes, please explain in space provided below.
Yes No *
Have you ever been employed by this Company? Yes No
Have you ever applied at this Company before? Yes No
Do you have relatives employed at this Company? If so, please give names in the space provided below. Yes No
Do you have friends employed at this Company? If so, please give names in the space provided below. Yes No
How soon are you available to begin employment? *
How were you referred: Career DayEmployeeFriendsNewspaperOtherReferralRehire
Shift Preference: DayEveningNight
Name, Address & Phone # of Employer:
Dates of Work: Position Held:
Salary: Duties:
Reason for Leaving:
May we contact this employer?: Yes No 1ST PREVIOUS
Name, Address & Phone # of Employer
May we contact this employer: Yes No 2ND PREVIOUS
May we contact this employer: Yes No 3RD PREVIOUS
May we contact this employer: Yes No
EDUCATION: (Please include: Dates Completed, Name of School & Location, & Diploma/degree)
High School
College
Business School
EMPLOYMENT LICENSES, REGISTRATIONS, OR CERTIFICATIONS: (Please include: Licenses, etc., State, Number, Date Issued & Expiration Date)
EQUIPMENT:
List Equipment you can operate:
TYPING:
Words per minute:
LANGUAGE SKILLS:
Language (other than English)
REFERENCES: (These include persons that are not friends or relatives) Please include: Names, Address, Telephone, Address, & Relationship
I authorize the investigation of all statements contained on this application and the references listed to give you any and all information concerning my previous employment, and release all persons from liability that may result from furnishing that information to Savoy Medical Center.
I certify that all information is true and correct to the best of my knowledge, and I understand that any false information, omissions, or misrepresentations of facts called for on this application may be cause for denial of employment, or discharge at any time.
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.
All employees of this Facility are employed for an indefinite period and the employer may terminate the employment relationship for cause. Cause is defined as a reason for disciplinary action that is not arbitrary, capricious, or illegal, that is based on facts that the employer reasonably believes to be true. Some examples of cause include but are not limited to, (1) dissatisfaction with an employee or such reasons as lack of capacity or diligence, failure to conform to usual standards of conduct, or other culpable or inappropriate behavior; or (2) economic needs subject to the reasonable judgment of the employer.
I have carefully read these statements and hereby declare my understanding of them and the opportunity granted to me to ask questions.
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