Application for Employment,

Transcription

1 Demographics / Background Applicant Name: SSN: First Middle Last Current : Previous : Home Phone: Mobile Phone: Are you at least 18 years old? Current open position for which you are applying: Date Available: Type(s) of Position: Shift(s) you can work: Salary Requirement: How did you learn about this position? Have you ever applied for a position at this facility? Have you ever worked in this facility? Are you legally eligible for employment in the United States? (Proof of U.S. citizenship or immigration status will be required upon employment) Are you able to perform the essential job related functions of the position for which you are applying with or without accomodations? - Accommodations Necessary: None Have you been convicted of a crime and/or released from confinement following a conviction for any criminal offense? Arrests or charges that have been expunged need not be disclosed. Disclose ALL misdemeanors and felonies. You may exclude minor traffic violations. Are you presently charged with any violation of the law? Page 1/5

2 Have you ever been sanctioned or been identified as an excluded provider for a federal or state health care program or have any such actions under investigation at this time? High School / GED: Education Name of School - City State Last Grade Graduated/GED? Degree or Certificate College / University: Name of School - City State Years Graduated? Degree or Certificate List any professional licenses registration or certification you possess (include Driver's License if applicable). 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 Indicate if any licenses have been revoked suspended or placed on probation.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. Clerical or other skills applicable to the position for which you are applying: Page 2/5

3 Employment History Current or Most Recent Employer: Company / Organization Phone # Name While Employed Immediate Supervisor May we contact them? Job Title Hours Per Week Starting Rate Ending Rate From To Reason for Leaving Nature of Duties / Responsibilities Page 3/5

4 References Reference #1: Name Relationship/Position () Phone # Years Known Reference #2: Name Relationship/Position () Phone # Years Known Applicant's Agreement Henderson Health Care Services Inc. (HHCS) is an Equal Opportunity Employer. EOE/AA In order to provide equal employment and advancement opportunities to all individuals employment decisions at HHCS will be based on merit qualifications and abilities. HHCS does not discriminate in employment opportunities or practices on the basis of race color religion gender national origin age disability or any other classification in accordance with federal state and local statutes regulations and ordinances. HHCS will maintain applications for as long as legally required. Upon application submission every effort will be taken to review it for proper consideration. If qualifications meet the current needs of HHCS our Human Resources Department will be in contact. HHCS is committed to providing a safe efficient and productive work environment for all employees. To help ensure a safe and healthful working environment each applicant to whom an offer of employment has been made will be required as a condition of employment to undergo a substance test. Applicants will be asked to read the policy and sign a Pre-Employment Offer and Employee Consent to Drug Screening. Effective July smoking and the use of tobacco products are not permitted on the HHCS campus or on any HHCS owned/leased properties or in hospital owned/leased vehicles. This policy applies to all individuals working visiting or receiving medical care within the boundaries of the hospital property. 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 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 Page 4/5

5 Powered by TCPDF ( material terms and is signed by me and the administrator of the facility. I understand that HHCS operates 24 hours a day seven days a week and that weekend work or temporary changes of shift may be required during employment. 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 and 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 and Medical Leave Act state civil rights acts the law of contract and the law of tort. I certify the information contained in this application for employment is true to the best of my knowledge and belief. I understand that any omission of facts or misrepresentation is cause for denial of employment and/or dismissal (if hired) regardless of when discovered. 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 HAVE READ AND AGREE TO THE ABOVE AND HEREBY CERTIFY THAT THE FACTS I HAVE PROVIDED IN MY EMPLOYMENT APPLICATION ARE TRUE AND COMPLETE. I have read and understand these conditions of employment and agree with the above statements. Written/Typed Agreement Full Name Date of Application Page 5/5