Application for Employment

Transcription

1 Application for Employment Cherokee Health Systems considers applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status or any legally protected status Only fully completed applications will be considered for employment Position(s) Applied For:_ Date of Application: (Position title is required for application to be processed. Applications that say any will not be accepted) Last Name First Name Middle Name Preferred Name/ Nickname Address City, State Zip Code Primary Phone Number _ Address Alt. Phone Number Social Security Number: (Voluntary) Are you 18 years of age or older? Yes No Have you ever been employed by Cherokee Health Systems? Yes No If yes, please provide dates of service: Do you have any family currently employed by Cherokee Health Systems? Yes No If yes, who? Are you legally permitted to work in the U.S.? Yes No Date(s) available for work What is your desired salary range? Are you available to work: Full-Time (please indicate: Mornings Afternoons Evenings Weekends) Part-Time (please indicate: Mornings Afternoons Evenings Weekends) Temporary (please indicate dates available: to Are you currently on layoff status and subject to recall? Yes No Can you travel if the position requires? Yes No Have you ever been discharged or forced to resign from a position? Yes No Education High School Name and Address of School Course of Study Years Completed Diploma/Degree Undergraduate College/University Graduate Professional Check Skills/Equipment: PC/Mac MS PowerPoint MS Excel MS Word Typing (WPM) Practice Management Software License/Certificate: Professional License or Certificate # Year Issued State(s) of Licensure Please select the preferred location(s) you are applying: Hamblen Cocke Loudon Union Grainger Claiborne Blount Sevier McMinn Knox Anderson Hamilton

2 Employment Experience When completing this section, start with your present or last job. Include any job-related military service assignments and volunteer activities. If you need additional space, please continue on a separate sheet of paper. Explain any lapses of employment during the last 5 years. Company Name Supervisor (Name and Title) Telephone Number(s) Address City, State Position Held Full-time Part-time Reason for leaving May we contact your current supervisor? Yes No Company Name Supervisor (Name and Title) Telephone Number(s) Address City, State Position Held Full-time Part-time Reason for leaving Company Name Supervisor (Name and Title) Telephone Number(s) Address City, State Position Held Full-time Part-time Reason for leaving Company Name Supervisor (Name and Title) Telephone Number(s) Address City, State Position Held Full-time Part-time Reason for leaving How did you hear about us? We would like to know how you found out about this job opening. Please take a moment to complete this section. Internet/Website: Trade Journal: Newspaper: Other: Cherokee Health Systems Employee(s):

3 References You must list a minimum of three (3) personal references (one of which has known you for at least five (5) years) and a minimum of three (3) professional references (one with at least five (5) years of direct knowledge of your qualifications for the position you seek). If you are a student or recent graduate you may list faculty/instructor references. Personal References Reference Name Phone Number How do you know this person? How long have you known this person? Alt. Phone Number Reference Name Phone Number How do you know this person? How long have you known this person? Alt. Phone Number Reference Name Phone Number How do you know this person? How long have you known this person? Alt. Phone Number Professional References Reference Name Phone Number How do you know this person? How long have you known this person? Alt. Phone Number Reference Name Phone Number How do you know this person? How long have you known this person? Alt. Phone Number Reference Name Phone Number How do you know this person? How long have you known this person? Alt. Phone Number Self Report of Legal and Criminal Actions If you answer yes to either of the following questions, please provide a detailed description of the events leading up to the issue, the outcome(s), and any additional information that claries the issue. 1. Have you ever been convicted of any crime, including felonies and/or misdemeanors, or plead nolo contendere, or any other form of non-guilty plea? Yes No 2. Has any government agency (i.e., license bureau, Medicaid, Medicare, state entity, etc.) ever suspended, revoked or taken any other action against your license to practice? Yes No

4 Applicant s Authorization I hereby authorize any of my employers and schools (list any exceptions and the reason): to release information contained in my records for purposes of processing my application. I also waive any action against them and Cherokee Health Systems should this information result in rejection of my application. Further, I understand that I will not have access to information collected in the process. Signature of Applicant: Date: Applicant s Authorization - - I certify that answers given herein are true and complete. - - I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. - - I understand that this application for employment shall be considered active for a period of time not to exceed 90 days. If I wish to be considered for employment beyond this time period, I 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 the 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 any application or interview(s) may result in discharge. I understand, also, that I am required to abide by all policies and procedures of the employer. - - My signature below acknowledges that this form, in original, faxed, photocopied, or electronic form will be considered valid consent for employment purposes. Signature of Applicant: Date: (an unsigned application will NOT be processed) Permission and Release Form for Reference Check Information Last Name First Name Middle Name Maiden/Former Name(s) Social Security Number Current Address City, State Zip Code I hereby authorize Cherokee Health Systems to conduct a reference check as part of my application process. I therefore authorize, request, and require any persons, institutions or other entities contacted to furnish Cherokee Health Systems with any information they have concerning work history, achievements, work skills, general reputation, and character. As a request to provide this information, I hereby release and forever discharge each and every person or institution from any and all claims of liability, in law or in equity that may arise out of furnishing such information to Cherokee Health Systems. I authorize Cherokee Health Systems to use such information in making decisions concerning my employment. My signature below indicates my understanding and acceptance of all the above terms and stipulations. I am signing this document voluntarily and without coercion. I acknowledge that this form, in original, faxed, photocopied or electronic form will be valid for employment purposes. Signature of Applicant: Date: (an unsigned application will NOT be processed) You may return this application by mail or fax. Cherokee Health Systems, Human Resources 2018 Western Avenue Knoxville, TN (865) Should you wish to return your application electronically, please send all applications and resumes to employment@cherokeehealth.com.

5 Affirmative Action Information Cherokee Health Systems requests the following information in order for our organization to comply with Equal Opportunity/ Affirmative Action (EEO) obligations. Data collected will be used for statistical purposes only and will be maintained separately. Your completion of this form is completely voluntary. Should you decline to supply this information you will not be subject to any adverse treatment. If you are unsure of how to complete these questions, please contact our Human Resource Department Please sign here if you choose NOT to answer the questions below Date Applicant EEO Information Instructions: If you wish to provide the following information, check one line only; If two or more ethnic categories are applicable, choose the one category with which you most closely identify. Gender: Female Male Ethnicity African American/Black American Indian/Alaskan Native Asian/Pacific Islander Hispanic/Latino White Two or More Races Other Veteran Status: Vietnam Era Veteran Disabled Veteran Recently Separated Veteran Armed Forces Active Reserves Not Applicable Other: Individual with Disabilities