Your Stay
General Information
Hospital Services
Keep Posted
Calendars
Community Links
Jobs
Foundation
Surveys/Feedback

Application For Employment
We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.

Position(s) Applied For
 Date of Application
31-Jul-10
How did you hear about us?
Advertisement Friend Walk-In
Employment Agency Relative Other 
Personal Information
Last Name:  First Name:  Middle Name: 
Street:  City:  State: 
Zip Code:  Social Security Number: 
Telephone Number(s): 
Email Address: 

Best time to contact you at home is: AM PM
If you are under 18 years of age, can you provide required proof of your eligibility to work? Yes No Not Applicable
Have you ever filed an application with us before? Yes No
If yes, give date:
Have you ever been employed with us before? Yes No
If yes, give date:
Do any of your friends or relatives, other than spouse, work here? Yes No
Are you currently employed? Yes No
May we contact your present employer? Yes No
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?
Proof of citizenship or immigration status will be required upon employment		 Yes No
On what date would you be available to work?
What is your desired salary range?
Are you available to work:  
Full Time (please indicate 1 2 3 shift)
Part Time (please indicate Mornings Afternoons Evening)
Temporary (please indicate dates available   -   )
Are you currently on "lay-off" status and subject to recall? Yes No
Can you travel if a job requires it? Yes No
Have you ever been convicted of a felony or a misdemeanor, or have you ever plead "no contest" to any criminal charges?
A criminal record does not constitute an automatic bar to employment and will be considered only as it relates to the job in question.		 Yes No
Provide date, city, state and an explanation for any "yes" responses:

Education
  Name and Address
of School		 Course of Study Years
Completed		 Diploma
Degree
Elementary
School
High
School
Undergraduate
College
Graduate
Professional
Other
(Specify)

Indicate any languages you can speak, read and/or write
  Fluent Good Fair
Speak
Read
Write

Describe any specialized training, apprenticeship, skills and extra-curricular activities.

Describe any job-related training received in the United States military.

Employment Experience
Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.
1. Employer
Dates Employed Work Performed
From To
Address
Telephone Number(s)
 Hourly Rate/Salary
Starting Final
Job Title
 Supervisor
Reason for Leaving
2. Employer
 Dates Employed Work Performed
From To
Address
Telephone Number(s)
 Hourly Rate/Salary
Starting Final
Job Title
 Supervisor
Reason for Leaving
3. Employer
 Dates Employed Work Performed
From To
Address
Telephone Number(s)
 Hourly Rate/Salary
Starting Final
Job Title
 Supervisor
Reason for Leaving
4. Employer
 Dates Employed Work Performed
From To
Address
Telephone Number(s)
 Hourly Rate/Salary
Starting Final
Job Title
 Supervisor
Reason for Leaving

List professional, trade, business or civic activities and offices held.
You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status:

Additional Information
Other Qualifications
Summarize special job-related skills and qualifications from employment or other experience.

Specialized Skills     (Check Skills/Equipment Operated)
Word
Excel
10 Key
Typing 		AS/400
Lotus Notes
PBX System
Medical Terminology 		Production/Mobile
Machinery (list):
 Other (list):

State any additional information you feel may be helpful to us in considering your application.

Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.
Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? A description of the activities involved in such a job or occupation is attached. Yes No
Not Informed

References
1
(Name)
Phone Number

(Address)
2
(Name)
Phone Number

(Address)
3
(Name)
Phone Number

(Address)

Diversity (For reporting purposes only)

We are an equal opportunity employer

Qualified applicants are considered for employment, and employees are treated during employment without regard to race, color, religion, national origin, citizenship, age, sex, marital status, ancestry, physical or mental disability, veteran status or sexual orientation.

Solely to help us comply with federal and state Equal Employment Opportunity record keeping, reporting, and other legal requirements, we request that you complete this data information questionnaire.

Refusal to complete this information will not subject any applicant or employee to adverse treatment. The information that you provide will be recorded and maintained in a confidential file, separate from all other records. This information will not be used in consideration for your employment.

Race/Ethnic Identification
White (Not of Hispanic origin): all persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Black (Not of Hispanic origin): all persons having origins in any of the Black racial groups of Africa.
Hispanic: all persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
Asian or Pacific Islander: all persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands and Samoa.
American Indian or Alaskan Native: all persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition.

Veteran Status
Special Disabled Veteran: (A) a veteran who is entitled to compensation (or who but for the receipt of military retired pay would be entitles to compensation) under laws administered by the Department of Veterans' Affairs for a disability (i) rated at 30 percent or more, or (ii) rated at 10 or 20 percent in the case of a veteran who has been determined under Section 3106 of Title 38, U.S.C. to have a serious employment handicap or (B) a person who was discharged or released from active duty because of a service-connected disability.
Vietnam Era Veteran: a person who (A) served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred: (i) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or (ii) between August 5, 1964 and May 7, 1975, in all other cases; or (B) was discharged or released from active duty for a service-connected disability if any part of such active duty was performed (i) in the Republic of Vietnam between February 28, 1961 and May 7, 1975; or (ii) between August 5, 1964 and May 7, 1975 in all other cases.
Other Veteran: veterans who served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized.

Persons with disabilities
An individual with a disability is any person who has a physical or mental impairment, which substantially limits one or more of such person's major life activities.

Gender


Ethnicity


Race


Recently Separated Veteran


Armed Forces Services Medal Veteran


Other Protected Veteran


I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will "nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also that I am required to abide by all rules and regulations of the employer.

E-Signature
By typing my name, I certify that the information contained in this application is true and accurate to the best of my knowledge. My typed name shall have the same force and effect as my written signature.

Please enter your full name in the box below:


     
Home | About Us | Contact Us | Privacy | © 2005 - 2010