Application for Employment March 2016


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APPLICATION FOR EMPLOYMENT

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.

 

Date: _________________

PLEASE PRINT

(Last Name)  

(First)
 

(Middle)
 

Primary Phone: 

(Street Address)

Alternate Phone:

(City)

(State)

(Zip)

Email address:

 

How were you referred to the hospital: ____________________________________________________________

Are you legally entitled to work in the United States?

Position you are applying for: ____________________________________________________________________

# Years of Experience in that position:__________________    Salary Expected: $____________ per ________

Willing to work:

Shifts You Are Available: 

Willing to work over-time?

Date Available to Begin Work_______________________________

Have you ever been employed with Cannon in the past:

If yes, when? ____________________  

EDUCATION:
Do you have a High School Diploma or GED:

 

High School

City, State

 

 

School Name

City, State

Degree Earned

 Major

College

 

College

 

Other

 

 

Have you, or do you currently serve in any branch of the military?

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?

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:

DATES

List Most Recent Employer First

EMPLOYER

INFORMATION

JOB TITLE AND SUPERVISOR

SALARY

EXACT REASON

FOR LEAVING

From:

Name:

My Job Title:

Starting:

To:

City, State:

My Supervisor:

Final:

Phone:

From:

Name:

My Job Title:

Starting:

To:

City, State:

My Supervisor:

Final:

Phone:

From:

Name:

My Job Title:

Starting:

To:

City, State:

My Supervisor:

Final:

Phone:

From:

Name:

My Job Title:

Starting:

To:

City, State:

My Supervisor:

Final:

Phone:

From:

Name:

My Job Title:

Starting:

To:

City, State:

My Supervisor:

Final:

Phone:

From:

Name:

My Job Title:

Starting:

To:

City, State:

My Supervisor:

Final:

Phone:

 

May we contact your current employer?

Have you ever pled guilty or been convicted of any offense other than a minor traffic violation?

If Yes, Please Explain:

Have you ever been excluded from participation in any state or federal healthcare program? 

If yes, please explain, including dates, facts, and current status:

 

Personal or Professional Reference (non-relative)

Occupation

Address

Telephone

 

 

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.

 

 Applicant’s Signature:

Signature Certificate
Document name: Application for Employment March 2016
Unique Document ID: 6e7e236db03685d241d090a8d89b971e2549200a
Timestamp Audit
2016-03-03 09:51:58 EDTApplication for Employment March 2016 Uploaded by Darren Crane - dcrane@indigoridge.com IP 24.177.16.74