Application for Employment March 2016
An Equal Employment Opportunity
The following information is requested in order to help us make the best possible placement within the hospital. All portions of this application that pertain to you must be completed. We appreciate the time you spend filling out the application. The hospital, in accordance with state and federal laws, does not discriminate on the basis of age, race, religion, color, sex, national origin, marital status, physical or mental handicap, or arrest record. Applications will remain active for one (1) calendar year.
How were you referred to the hospital: ____________________________________________________________
Are you legally entitled to work in the United States? YES NO
Position you are applying for: ____________________________________________________________________
# Years of Experience in that position:__________________ Salary Expected: $____________ per ________
Willing to work: Full-time Part-time PRN
Shifts You Are Available: 1st 2nd 3rd
Willing to work over-time? YES NO
Date Available to Begin Work_______________________________
Have you ever been employed with Cannon in the past: YES NO
If yes, when? ____________________ EDUCATION:Do you have a High School Diploma or GED: YES NO
Have you, or do you currently serve in any branch of the military? YES NO
List professional licenses, certifications, and registrations:
Has your professional license, certification, or registration ever been suspended or revoked, or have you ever been under disciplinary action by your licensing board? YES NO
If Yes, please explain:List any noteworthy achievements or special training and skills including computer skills:
EMPLOYMENT RECORD: Please complete even if you have provided a resume:
List Most Recent Employer First
JOB TITLE AND SUPERVISOR
My Job Title:
May we contact your current employer? YES NO
Have you ever pled guilty or been convicted of any offense other than a minor traffic violation? YES NO
If Yes, Please Explain:
Have you ever been excluded from participation in any state or federal healthcare program? YES NO
If yes, please explain, including dates, facts, and current status:
Personal or Professional Reference (non-relative)
STATEMENT OF UNDERSTANDING:I certify that all of the information in my application is true, accurate, and complete to the best of my knowledge. I understand that as a part of the procedure for processing my employment application, an investigation may be made into my background. I hereby authorize this investigation into all matters contained in this form and authorize schools, prior employers, references, physician and other medical practitioners to provide to Cannon Memorial Hospital my record, reason for leaving, and all other information they may have concerning me. I release all parties from any and all liability or claims for damage whatsoever that may result there from. I agree that if, in the judgment of Cannon Memorial Hospital, any misrepresentation has been made herein or in a subsequently executed medical questionnaire, or the results of such background investigation are not satisfactory, any offer of employment may be withdrawn, or my employment may be terminated immediately, without any obligation or liability to me other than for payment at the rate agreed upon for services actually rendered.
Any educational degree or certification required as a condition of employment must have been obtained from an accredited institution; at the time such degree or certification was conferred upon the applicant, by the Council for Higher Education Accreditation or one of its affiliated accrediting organizations.
IF CANNON MEMORIAL EMPLOYS ME, I UNDERSTAND THAT NO POLICY WITHIN THE CANNON MEMORIAL POLICIES & PROCEDURES MANUAL CREATES A CONTRACT OF EMPLOYMENT. CONSISTENT WITH SOUTH CAROLINA LAW, ALL EMPLOYEES ARE AT-WILL WHICH MEANS THAT THE EMPLOYEE HAS THE RIGHT TO TERMINATE HIS OR HER EMPLOYMENT AT ANY TIME, WITH OR WITHOUT NOTICE OR CAUSE, AND THAT CANNON MEMORIAL RETAINS THE SAME RIGHT. EXCEPTIONS TO THE POLICY THAT ALL EMPLOYEES ARE AT-WILL MAY BE MADE ONLY BY WRITTEN AGREEMENT SIGNED BY THE CEO OR PRESIDENT OF CANNON MEMORIAL.
I understand that any offer of employment is contingent upon satisfactorily passing a background check, drug screen, and post-offer pre-employment test.My typed name below shall have the same force and effect as my written signature.
If you have questions about the contents of this document, you can email the document owner.
Document Name: Application for Employment March 2016
Agree & Sign