RIVER HOSPITAL 4 FULLER STREET ALEXANDRIA BAY, NY APPLICATION FOR EMPLOYMENT

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1 For Office Use Only RIVER HOSPITAL 4 FULLER STREET ALEXANDRIA BAY, NY APPLICATION FOR EMPLOYMENT (Retained for One Year) Please fill out this form fully, accurately, and IN YOUR OWN HANDWRITING. Your cooperation will help us deal with the application more effectively. A personal interview may be requested only after evaluation of your work experience, skills, applicable education and at a request of a department manager. NOTE: The New York State Anti-discrimination Law and Federal Laws do not allow discrimination because of age, race, creed, color, national origin, sex, marital status, disability, or sexual orientation. We are an equal opportunity employer. Any offer of employment is subject to the application meeting the health standards of the Hospital/Home and physical requirements of the job in question. I. PERSONAL: Date NAME: Last First Middle POSITIONS APPLIED FOR: FULL TIME PART TIME PER DIEM Social Security Number Visa Number (if not U.S. Citizen) (Are you eligible for employment Address: in this country?) Yes No Address: Street City County State Zip Code Home Phone: ( ) Business Phone: ( ) May we call you at work? Yes No Have you filled out an application here before? Yes No Are you 18 years of age or over? Yes No If no, are you at least 17 years of age? Yes No If under 18, please enclose a copy of your working papers. Enclosed Yes No II. EDUCATION: Circle highest grade completed Graduate Degree Name of School Location Courses/Major Diploma/Degree Licensure Certification Necessary for Professional or Technical Position (not driver s license) N.Y.S. License Profession Certification

2 III. MILITARY: Branch of Service From To Applicable Experience IV. OTHER INQUIRY: Have you ever been convicted of a crime? (A conviction does not automatically disqualify you from employment.) If yes, explain. Are you proficient in any language other than English? If so, what language (including sign language) _ V. PERSONAL REFERENCES: May we contact your PRESENT Employer(s) for references? May we contact your PREVIOUS Employer(s) for references? Give the names and addresses of three persons NOT employers and NOT relatives, who have known you for several years: BE SURE TO PROVIDE COMPLETE MAILING ADDRESSES AND TELEPHONE NUMBERS Is additional information regarding your use of a DIFFERENT NAME necessary for us to check your past work references? If yes, explain: VI. FOR APPLICANT USE: List any information which you feel will be helpful in considering you for employment:

3 VII. PREVIOUS EXPERIENCE: PLEASE BE ACCURATE AND COMPLETE IN PROVIDING ALL DATA List LAST four positions, giving last position first:

4 VIII. APPLICANT UNDERSTANDING: THE FOLLOWING STATEMENT IS PART OF THIS APPLICATION, READ IT CAREFULLY AND SIGN BELOW: I understand that any omission or misrepresentation of material fact in this application may result in refusal of or separation from employment. I hereby authorize The River Hospital to make check of my physical condition and any reference check of my employment background and hereby waive any right to see the reference obtained. I understand that I will be required to provide Private Health Information to fulfill Department of Health requirements. I understand no offer of employment or policy or procedure of the employer shall constitute a contract of employment, and no representative of the employer has the authority to make a contract of employment. I have agreed to submit this application by electronic means. By signing this application electronically, I certify that my answers are correct and complete to the best of my knowledge. I understand that an electronic signature has the same effect as a handwritten signature, and any false information may result in the denial of my application or later termination if employed. IX. INTERVIEW ANALYSIS: Human Resources Comments Department Manager s Comments X. HUMAN RESOURCES & DEPARTMENT HEAD: Position Code: Position Title: Shift: Grade: Rate of Pay: Cost Center: Replacing: Physical Exam Date: Department Name: Hire Date: Approvals: Department Head Human Resources

5 CONFIDENTIAL River Hospital Affirmative Action Questionnaire This is not a part of the application and is removed before screening. It is used for AAVEEO purposes only. No individual personnel selections are made based on the information. Please answer the following questions to the best of your ability. Your cooperation is appreciated. ETHNIC CATEGORY 1) White (not Hispanic origin). All persons having origins in any of the original peoples of Europe, North Africa and the Middle East. 2) Black( not of Hispanic origin). All persons having origins in any of the Black racial groups of Africa. 3) Hispanic. All persons of Mexico, Puerto Rico, Cuba, Central or South America, or other Spanish culture or origin regardless of race. 4) 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, Japan, Korea, the Philippine Islands, and Samoa. 5) American Indian or Alaskan Native. All persons having origins in any of the original peoples of North America are who maintain cultural identification through tribal affiliation or community recognition. 6) Other: Position Applied for Date I learned about this job opening through: A friend or relative An employee Personnel Office Employment Announcement Gender: Male Female Job Fair, organization, or group(which?): Advertisement (which paper or magazine?): Website (please specify site): Other Means (Please specify): Age: Are you 40 years of age or older? Yes No

Are you legally eligible for employment in the United States? Yes No When will you be available to begin work?

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