APPLICATION FOR EMPLOYMENT

Transcription

1 DATE: APPLICATION FOR EMPLOYMENT NEMAHA COUNTY HOSPITAL TH STREET AUBURN, NE (402) FAX: (402) Nemaha County Hospital is an equal opportunity employer. NCH does not discriminate against any employee or applicant on the basis of race, color, national origin, sex, disability, religion, age, veteran status, or any other basis protected by law. Inquiries regarding non-discrimination policies and practices should be directed to the Human Resource Department Nemaha County Hospital. Applicants who need a reasonable accommodation during the selection process may contact Human Resources for assistance. All applications will be kept on file for 60 days. GENERAL INFORMATION Name: Last First Middle Name Last 4-digits of Social Security # Have you worked under other names? If yes, -- Name(s) Street Address/Apt No. City State Zip Code Day Telephone Number: Evening Telephone Number Cell Number Address: ( ) ( ) ( ) Do you have relatives employed at NCH? Yes No If yes, list name and relationship: Were you formerly employed at Nemaha County Hospital? If so, list date(s) Are you 18 years of age or older? Yes No If hired, can you provide proof of your eligibility to be employed in the United States? Yes No POSITION INFORMATION Desired Hours: Full-time Part-time PRN Days Evenings Nights # of hours desired: Position applied for: Job Title: How Were You Referred to Nemaha County Hospital? Employee referral Employee Name Internet List Site Newspaper Job Fair List Location Radio Walk-in! 1

2 Other EDUCATION AND TRAINING RECORD Circle highest grade completed: G.E.D Name and Location of College or Vocational Education Certificate/Degree Received Major or Specialty Graduated Yes No Dates Attended Has your professional license (in any state) ever been on probation, suspended, revoked, or limited in any way? Yes No Note: Pharmacy Supportive Personnel Applicants Only: In compliance with the Nebraska Department of Health, my initials below and subsequent signature on this application affirm the following information: I am at least 18 years of age or older, (2) I have graduated from high school or have obtained an equivalent education, and (3) I have never been convicted of a drug-related misdemeanor or felony. Initials: Have you ever been discharged or terminated from a job? Yes No If yes, please explain (list employer dates, reason and explanation): Have you ever been convicted of ANY crime within the last seven (7) years? (Conviction will not necessarily disqualify applicant from employment). Yes No Disclose ALL misdemeanors and felonies (including Driving under the Influence (DUI), Minor in Possession (MIP), etc. You may exclude minor traffic violations. Applicants are not obligated to disclose any sealed criminal record. If yes, please explain: Have you even been convicted of a criminal offense related to healthcare? Yes No If yes, please explain: Are you currently excluded, debarred or ineligible for participation in a federal health care program such as Medicare, Medicaid or the Civilian Health and Medical Program of the Uniformed Services? Yes No I hereby certify that all answers given by me are true, accurate and complete. I understand that the falsification, misrepresentation or omission of fact on this application (or any other accompanying documents) will be cause for denial of employment or immediate termination of employment, regardless of when or how it was discovered. I understand that this employment application or any other key document or agreement, either written or oral, are not contracts of employment. I agree to conform to the rules and regulations of Nemaha County Hospital, if accepted for employment, and understand that my employment and compensation can be terminated, with or without cause, and with or without notice, at any point in time, at the option of either Nemaha County Hospital or myself. I furthermore understand that any offer of employment will be contingent upon my being able to prove eligibility for employment as required by the Immigration Reform and Control Act and upon satisfactory completion of post-offer health and drug screening. I am aware that a consumer report, including an investigative consumer report containing information as to my character, general reputation, personal characteristics, and mode of living, may be obtained for employment purposes as part of the pre-employment background investigation and at any time during my employment, and that such a check may be conducted by an outside source. I will sign a separate disclosure as required by law if these reports are necessary for the position that I am making application. I furthermore acknowledge and assent that such outside agencies may keep and use the information they supply to Nemaha County Hospital during this investigation for their own purposes. I release third parties, Nemaha County Hospital and its employees! 2

3 from any claims arising out of these authorizations. I understand that such information as the name of the investigating company or the nature and scope of such inquiry, if one is necessary, is available to me upon my written request, in conformance with the Fair Credit Reporting Act of 1970, as amended by the Consumer Credit Reporting Act of I authorize and release current and previous employers, individuals, personal references, schools and organizations to provide Nemaha County Hospital with any relevant information that may be required to arrive at an employment decision, and release such individuals providing references from any liability. Signature Date APPLICATIONS WHICH ARE NOT SIGNED WILL NOT BE CONSIDERED EMPLOYMENT HISTORY Nemaha County Hospital is an EEO Employer/Vet/Disabled List your present or most recent employer FIRST. Include U.S. Armed Forces Experience. Account for All the time during the past 10 years including period of unemployment. Include any unpaid work experience. (Attach additional pages as needed). Omit reasons for leaving if for reasons of health disability. Resumes are acceptable but may NOT be substituted for the following information. Company Telephone Fax Address City State-Zip Employed (month and year) From Name of Supervisor Job Title Salary Start Reason for leaving To Last Job Duties May we contact employer? If no, why? Company Telephone Fax Address City State-Zip Employed (month and year) From Name of Supervisor Job Title Salary Start Reason for leaving To Last Job Duties May be contact employer? If no, why? Company Telephone Fax Address City State-Zip Employed (month and year) From Name of Supervisor Job Title Salary Start Reason for leaving To Last Job Duties May we contact employer? If no, why?! 3

4 Company Telephone Fax Address City State-Zip Employed (month and year) From Name of Supervisor Job Title Salary Start Reason for leaving To Last Job Duties May we contact employer? If no, why? HR Forms: 135PF1003 Revised 2/00, 4/00, 6/00/3/04, 11/04, 01/08, 1/1, 4/12, 1/13, 3/14, 5/14, 12/17 MSSION STATEMENT Quality Care Every Time CORE VALUES Integrity, Compassion, Accountability, Respect, Excellence! 4

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