APPLICATION FOR EMPLOYMENT

Transcription

1 APPLICATION FOR EMPLOYMENT Edgefield County Hospital 300 Ridge Medical Plaza, Edgefield, South Carolina Fax We are pleased that you are seeking employment at Edgefield County Hospital. Edgefield County Hospital is an equal opportunity employer. It is our policy to provide equal employment opportunities to all persons in compliance with applicable federal and state laws, rules and regulations. This policy relates to all phases of employment including, but not limited to, recruitment, selection, promotion, transfer and training. No question on this application is intended to secure any information contrary to this policy. Employment at Edgefield County Hospital is at-will. Your employment and compensation can be terminated with or without reason, and with or without notice, at any time at the option of Edgefield County Hospital or yourself. Employees are free to quit at any time and for any reason. Edgefield County Hospital has the same right to terminate the employment relationship. Any statements contrary to this provision have no force or effect unless they are in writing and signed by the CEO of Edgefield County Hospital. No officer, agent, or employee of Edgefield County Hospital other than the CEO has authority to enter into any agreement for employment, for any specified period of time, or to make any agreement contrary to the foregoing. Please fill out all of the sections below: Applicant Information Applicant Name: Address: Telephone Number: Address: Social Security Number Date of Application: 1

2 Employment Position Position(s) applying for: How did you hear about this position? What days are you available for work? What hours or shift are you available for work? If needed, are you available to work overtime? On what date can you start working if you are hired? Salary desired: Personal Information Have you ever applied to or worked for Edgefield County Hospital before? Yes No If yes, when? Do you have any friends, relatives, or acquaintances working for Edgefield County Hospital Yes No If yes, state name & relationship: Are you 18 years of age or older? Yes No Are you a U.S. citizen or approved to work in the United States? Yes No What document can you provide as proof of citizenship or legal status? Have you ever been convicted of a criminal offense (felony or misdemeanor)? Yes No If yes, please state the nature of the crime(s), when and where convicted and disposition of the case: Job Skills/Qualifications Please list below the skills and qualifications you possess for the position for which you are applying: 2

3 Education and Training High School College/University Vocational School/Specialized Training Military: Are you a member of the Armed Services? What branch of the military did you enlist? What was your military rank when discharged? How many years did you serve in the military? What military skills do you possess that would be an asset for this position? Professional Licenses and/or Certifications Name State Number Expiration Date 3

4 Previous Employment References Please provide 3 personal and professional reference(s) below: Reference Contact Information 4

5 STATEMENT OF UNDERSTANDING I authorize the investigation of all statements contained in this application. I understand that any misrepresentation or omission of facts is reason for dismissal at any time without previous notice. I authorize the investigation of all matters contained in this application and hereby give Edgefield County Hospital permission to contact schools, previous employers (unless otherwise indicated), and references and hereby release Edgefield County Hospital from any liability as a result of such contact. I authorize each of the employers listed above to release information regarding my employment with that employer. I understand that offers of employment are contingent upon my passing a background check and preemployment screening tests administered by Edgefield County Hospital, and I agree to annual PPD screenings that are required by Edgefield County Hospital. I am also aware that Edgefield County Hospital does require screening for drug or alcohol use as part of such pre-employment. Applications will remain active for a period of ninety (90) days. If you are not hired within that ninety (90) day period, but still desire to be considered for employment please complete a new application. Applicant Signature: Dated: 5