Job Application - Sheridan Community Hospital

* Please note that your information will not be encrypted as it is electronically sent to Sheridan Community Hospital. If you choose, feel free to remove any sensitive information from the application above.


Have you ever filed an application with us before?		Yes No If yes, when
Position Applied For

Contact Information

Name (Last, First, Middle; please include any former names if applicable)
Telephone Number
Email
Street Address

City
State
Zip Code
How many years at this address?
Previous Street Address

City
State
Zip Code
How many years at this address?

Salary Expectation ($___ per___)
What days and times are you available to work?
What shifts are you willing to work?
Date available for work
Employment Status desired		Full Time Part Time
Have you ever been employed by Sheridan Hospital?		Yes No
		In what department?
		In what position?
		Date Started
		Date Left
		Reason for leaving
Are you a U.S. citizen?		Yes No
If you are not a U.S. citizen, do you have a legal right to remain permanently in the U.S.?		Yes No
If employed, can you submit verification of your legal right to remain in the U.S.?		Yes No
Are you 18 years or over?		Yes No
How did you learn of this position?
Do you have a reliable form of transportation availble for you to go to and from work?		Yes No

Military Service

Service
Branch
	Dates of Service
Were you honorably discharged?		Yes No
Reserve Status
Descrive any specialized training and duties

Employment History
List your last four employers, or all employers for the last ten years, whiever is greater. Also, list and explain any period(s) of unemployment. Please answer all inquiries. "See Resume" is not acceptable.
Employer Name
	Address
	City, State, ZIP
	Job Title
	Supervisor
	Supervisor's Title
	Reason for Leaving
	Dates Employed
	Salary
	Duties and Reponsibilities
Employer Name
	Address
	City, State, ZIP
	Job Title
	Supervisor
	Supervisor's Title
	Reason for Leaving
	Dates Employed
	Salary
	Duties and Reponsibilities
Employer Name
	Address
	City, State, ZIP
	Job Title
	Supervisor
	Supervisor's Title
	Reason for Leaving
	Dates Employed
	Salary
	Duties and Reponsibilities
Employer Name
	Address
	City, State, ZIP
	Job Title
	Supervisor
	Supervisor's Title
	Reason for Leaving
	Dates Employed
	Salary
	Duties and Reponsibilities
Are you currently on "layoff" status and subject to recall?		Yes No
Have you ever been discharged by an employer or resigned in lieu of discharge?		Yes No
Have you ever been disciplined (other than discharged) by an employer?		Yes No
If you answered yes to either of the two previous questions, explain all such incidents, giving facts, dates and describing any action you took and any resolution.
How much time have you missed from work in the past 12 months?
Do you have a valid driver's license?		Yes No

Education

High School/GED		Name
		Location
		Did you graduate? Yes No
Business School		Name
		Location
		Degree(s) earned
College/University		Name
		Location
		Degree(s) earned
Trade/Vocation School		Name
		Location
		Degree(s) earned
Extracurricular activities and honors received in school
Professional Licenses, Registrations and/or Certifications

List all states in which you are or have been licensed or certified and any national certifications.
Have you ever had any professional license or certification placed under investigation, disciplined, suspended, revoked or put on probation?		Yes No
Have you ever been denied a license or certification?		Yes No
If you answered yes to either of the above questions, please explain in detail

Miscellaneous

Have you ever been convicted of a felony?		Yes No
Do you have any felony charges pending against you?		Yes No
If you answered yes to any of the three preceeding questions, explain by giving the date, nature of the offense and circumstances. Conviction of a crime will not necessarily disquality an applicant from employment.

References

Give the name, address and telephone numbers of three references who are not related to you
Name
	Telephone
	Address
	City, State, ZIP
Name
	Telephone
	Address
	City, State, ZIP
Name
	Telephone
	Address
	City, State, ZIP
Statement of Release and Correctness
I have read and fully understand the questions on this application for employment. I have completely, truthfully and accurately answered each and every question to the best of my knowledge. I understand that all the inquiries on this application are subject to verification and authorize any schools that I have attended, licensing and certification boards, current and previous employers, law enforcement agencies, traffic record sources, etc. and, as permitted, to release any requested information to Sheridan Community Hospital. I also specifically waive written notice from any and all former employers regarding their disclosure to the Hospital of any prior disciplinary action and waive any claim against the Hospital and current or former employers arising from such investigation or disclosure. I understand that any misrepre- sentation, false statement or omission of the information I have supplied or failed to supply can result in a rejection of this application or, if I have been hired, an immediate dismissal at the sole discretion of the Hospital. I understand and agree that in the absence of an express written contract or agreement to the contrary, signed by an authorized executive of the Hospital and by me or my authorized representative, any employment I accept shall be for an indefinite term and may be terminated at any time with or without cause either by me or at the will and sole discretion of the Hospital regardless of any contrary provisions in any other forms, manuals, handbooks or other documents. Similarly, such employment shall be at the wages, benefits, hours, and conditions as the Hospital may determine and change from time to time and I agree to abide by any rules, regulations, policies, and procedures that may be established from time to time. I understand that no one, other than an authorized executive of the Hospitalhas any authority to enter into an agreement with me contrary to the provisions of this paragraph and that any such agreement must be in writing and signed by such authorized executive or it shall not be effective by the Bullard Plawecki Right to Know Act. I understand and agree if I am offered employment, the offer is conditioned upon satisfactory completion of a physical examination, drug screening, criminal background check and/or fingerprinting, references and other background checking prior to beginning employment and that I must satisfactorily pass all such examinations to obtain employment. I also understand that any claim or lawsuit relating to my service with Sheridan Community Hospital or any of its subsidiaries must be filed no more than six months after the date of employment action that is the subject of the claim or lawsuit. I waive any statue of limitations to the contrary. I have read and agree to the above statement of release and correctness.


* Please note that your information will not be encrypted as it is electronically sent to Sheridan Community Hospital. If you choose, feel free to remove any sensitive information from the application above.

Employment Application