Employment Application


   
  Have you ever filed an application with us before? Yes No
  If yes, when?  
  Position Applying 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 Community 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 valid driver's license? Yes No  
  Do you have reliable transportation to get to and from work? Yes No
 
     
  Military Service  
     
  Service  
  Branch  
    Dates of Service  
  Were you honorably discharged? Yes No  
  Reserve Status  
  Describe any specialized training and duties  
     
  Employment History  
     
  List your last four employers, or all employers for the last ten years, whichever 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?  
     
  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 either of the two previous questions, explain by giving the date, nature of the offense and circumstances. Conviction of a crime will not necessarily disqualify 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 Hospital has 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 statute of limitations to the contrary.

I have read and agree to the above statement of release and correctness.
 
 
  Verification    
  Please confirm you are not a robot submitting this form and type "Sheridan" in this field.  
      
 
 


 

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