Please Complete All Fields
Application Date:
[Application_date]
Referred By:
[Referred_by]
Name
[realname]
Email Address
[email]
Present Address (Street, City, State, Zip)
[Address]
Telephone:
Home:
[Telephone_Home]
Business:
[Telephone_business]
Other
[Telephone_Other]
I am available:
[Available_To_Work]
Full Time
[Available_To_Work]
Part Time
If Part Time specify hours available:
[Part_time_hours_available]
Shift desired:
[Shift_day]
Day
[Shift_evening]
Evening
[Shift_night]
Night
Date Available for work:
[Date_available_for_work]
Position(s) applying for:
[Positions_applied_for]
(Nursing applicants list specialty)
[Nurse_specialty]
|
Social Security Number:
[Social_security_number]
|
Have you ever been employed by us?
[Previously_employed_by_HCMH]
Yes
[Previously_employed_by_HCMH]
No
If yes, when?
[If_yes_When]
Are you a U.S. Citizen?
[US_Citizen]
Yes
[US_Citizen]
No
If no, visa type
[Visa_type]
Date Granted:
[Date_granted]
|
| Highest grade completed: 1-12
[Highest_grade_completed]
College or Tech: 1-7
[College_or_Tech_completed]
|
| Type of School |
School Name & Address |
Major |
Minor |
Degree Received |
Dates Attended |
| High School |
[High_school_name_address]
|
[Major]
|
[Minor]
|
[Degree_received]
|
[Dates_attended_HighSchool]
|
| College |
[College_name_address]
|
[Major]
|
[Minor]
|
[Degree_received]
|
[Dates_attended_College]
|
| Graduate School |
[Grad_school_name_address]
|
[Major]
|
[Minor]
|
[Degree_received]
|
[Dates_attended_GradSchool]
|
Fields of work for which you are licensed, or certified:
[Fields_licensed_or_certified]
Certificate/License No.
[Certificate_or_License_number]
Renewal No.
[Renewal_number]
Year of License
[Year_of_license]
Special skills you wish considered:
[Special_skills]
===================================================================================
Have you ever been convicted of or forfeited bond in connection with a criminal offense?
[Criminal_convictions]
Yes
[Criminal_convictions]
No
If yes, explain:
[Criminal_Convictions_Explanation]
List the names of departments of HCHS in which relatives are employed:
[Departments_where_relatives_work]
===================================================================================
| Name |
Address |
Telephone Number |
| [References_Name1] |
[References_address_1] |
W.
[References_work_telephone_1] |
| H.
[References_home_telephone_1] |
| [References_Name_2] |
[References_address_2] |
H.
[References_Home_telephone_2] |
| W.
[References_Work_telephone_2] |
| [References_Name_3] |
[References_address_3] |
H.
[References_Home_telephone_3] |
| W.
[References_Work_telephone_3] |
Please give accurate, complete full-time and part-time employment record. Start with present or most recent employer.
Company Name
[Employment_History_Company_Name1]
Address
[Employment_History_address1]
Name and Title of Superior
[Employment_Superior_Name_and_Title1]
State Job Title and Describe your work
[Job_full_time1]
Full time
[Job_part_time1]
Part time
[Job_description1]
|
Telephone
[Employment_History_telephone_number1]
|
Employed (State month and Year)
From:
[Employed_from1]
To:
[Employed_to1]
|
Hourly Pay
Start:
[Hourly_pay_START1]
Last:
[Hourly_pay_LAST1]
|
Reason for Leaving
[Reasons_for_leaving_job1]
|
Company Name
[Employment_History_Company_Name2]
Address
[Employment_History_address2]
Name and Title of Superior
[Employment_Superior_Name_and_Title2]
State Job Title and Describe your work
[Job_full_time2]
Full time
[Job_part_time2]
Part time
[Job_description2]
|
Telephone
[Employment_History_telephone_number2]
|
Employed (State month and Year)
From:
[Employed_from2]
To:
[Employed_to2]
|
Hourly Pay
Start:
[Hourly_pay_START2]
Last:
[Hourly_pay_LAST2]
|
Reason for Leaving
[Reasons_for_leaving_job2]
|
Company Name
[Employment_History_Company_Name3]
Address
[Employment_History_address3]
Name and Title of Superior
[Employment_Superior_Name_and_Title3]
State Job Title and Describe your work
[Job_full_time3]
Full time
[Job_part_time3]
Part time
[Job_description3]
|
Telephone
[Employment_History_telephone_number3]
|
Employed (State month and Year)
From:
[Employed_from3]
To:
[Employed_to3]
|
Hourly Pay
Start:
[Hourly_pay_START3]
Last:
[Hourly_pay_LAST3]
|
Reason for Leaving
[Reasons_for_leaving_job3]
|
Military Service
Have you ever served in the U.S. Military?
[Military_service]
Yes
[Military_service]
No
Please list any job-related skills or experience:
[Job_skills_experience]
|
Statement Of Health
Can you perform the essential functions of the position for which you are applying safely?
[Perform_job]
Yes
[Perform_job]
No
Explain:
[Health_statement]
|
Are you willing to take a physical examination, drug test and criminal record check at our expense upon a conditional offer of employment?
[Physical_exam]
Yes
[Physical_exam]
No
Have you ever been sanctioned by or excluded from participation in Medicare, Medicaid or any
government health program?
[Sanctions_from_Health_Agencies]
Yes
[Sanctions_from_Health_Agencies]
No
Are you currently under investigation for sanctioned issues?
[Currently_under_investigation_for_sanctions]
Yes
[Currently_under_investigation_for_sanctions]
No
May we contact your present employer?
[May_we_contact_your_employer]
Yes
[May_we_contact_your_employer]
No
Affidavit. I certify that the answers given by me in the foregoing questions are true and correct without consequential omissions of any kind whatsoever, I agree that my employer shall not be liable in any respect if my employment is terminated because of falsity of statements, answers or omissions made by me in this question. I authorize employers, companies, schools or persons named above to give information regarding my employment, together with any information that they may have regarding me whether or not it is in their records. I hereby release said employers, companies, schools or persons from all liability for any damages, both legal and otherwise, for issuing this information. I also understand a conditional offer of employment may be based on the results of a later medical examination. In addition. if accepted for employment, I hereby agree to abide by the rules and policies of my employer. Further, I understand that any employment is not for a stated period of time and may be terminated with or without cause, at any time, at the option of either my employer or myself. In addition, should my employer be or become subject to the conditions of the Drug Free Workplace Act of 1988, I agree to abide by such established policies as related thereto.
_ ________________________________________________________________________
We are a equal opportunity employer-a copy of this application is available to you upon request. |
Hugh Chatham Memorial Hospital PO Box 560, Elkin NC 28621 (336)527-7660 Fax (336)527-7663 www.hughchatham.org
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