Employment Application

EMPLOYMENT APPLICATION

PERSONAL

Last Name:	First Name:	Middle Initial:
Address:
City:	State:	Zip Code:
E-Mail:
Home Phone:	Cell Phone:
If you are under age 18, do you have a work permit?		Yes No
Are you authorized to work in the United States?		Yes No

Describe the position for which you are applying:

	Reference #		Pay desired $		per
Date available for employement

Check all shifts that you are available to work.

Check first preference.

How did you learn of this opening?

	Full-Time	Part-Time	Per Diem
Days
Evenings
Nights
12 Hour Shift
Will you work weekends?		Yes	No

	Advertisement (specify where):
	Referral by:
	Career Day / Job Fair (specify when/where):
	Walk-in:

Have you ever applied to or been employed by Saint Clare’s Hospital, any of its former hospitals (Northwest Covenant Medical Center, St Clares Riverside Medical Center, Dover General Hospital & Medical Center, Wallkill Valley Hospital) or its affiliate organizations?
Applied Employed No If employed, which facility?
If employed by Saint Clare’s Hospital or its affiliate organizations, have you ever been discharged from a position or asked to resign (other than position elimination)?
Yes No If Yes, please explain
Please list any other names you have used for education, employment and licensure:
List any relatives working for use and the position they hold:
Are you an immediate family member of an Independent Licensed Practitioner (i.e., Physician, Advanced Practice Nurse, Psychiatrist, etc.) who works for Saint Clare’s Hospital or its affiliate organizations?
Yes No
Have you ever been convicted of or pled guilty to a crime, other than a traffic violation, which has not been expunged or sealed by a court?
Yes No
Are you currently excluded (or being investigated for exclusion) from providing healthcare services in any federal funded program, including Medicaid or Medicare?
Yes No
If yes to either of the above, describe fully the criminal conviction(s) or exclusion, listing the nature of offense and your rehabilitation since the conviction(s). A conviction or exclusion record will not necessarily be a barrier to employment.

EDUCATIONAL BACKGROUND

Check Highest Year Completed	1 2 3 4 5 6 7 8	9 10 11 12	1 2 3 4	1 2 3 4
	Grammar School	High School	College	Post Graduate

High School / College(s) / Trade Schools Attended

NAME & ADDRESS	MAJOR	# Credit Completed	Diploma / Degree

Professional / Business Schools

NAME & ADDRESS	TYPE OF PROGRAM	DIPLOMA / CERTIFICATE

PROFESSIONAL LICENSES AND / OR CERTIFICATIONS

Are you currently:

Registered Licensed Certified

Are you eligible for:

Registration Licensure Certification

In what field

If licensed, registered or certified:

Type	State Issued	Date	No.
Type	State Issued	Date	No.
Type	State Issued	Date	No.

Has your license ever been under review because of activity related to patient care or the performance of your duties in your profession? Yes No

Has your license ever been revoked or suspended because of activity related to patient care or the performance of your duties in your profession? Yes No

MILITARY SERVICE RECORD

Have you ever served in the U.S. Armed Forces? Yes No	If yes, what branch?
Dates of duty: From to	Rank at discharge
Describe your duties including special training and duty station:

EMPLOYMENT HISTORY (Please start with last employer or present place of employment.)

1. Employer May we contact at present time? Yes No	Employed from to
Address	Phone
Last Position	Salary
Name and title of supervisor
Brief description of duties
Reason for leaving
Name of reference

2. Employer May we contact at present time? Yes No	Employed from to
Address	Phone
Last Position	Salary
Name and title of supervisor
Brief description of duties
Reason for leaving
Name of reference

3. Employer May we contact at present time? Yes No	Employed from to
Address	Phone
Last Position	Salary
Name and title of supervisor
Brief description of duties
Reason for leaving
Name of reference

Please identify and explain any gaps in employment longer than three months.

CHECK SKILLS / EQUIPMENT OPERATED

PC	Phone System	Word	Production / Mobile Machinery (list):
Calculator	Dictaphone	Excel
Keyboarding WPM	Steno	Powerpoint
Fax	Windows	Access	Other:

REFERENCES (List at least three professional references.)

NAME	TITLE	COMPANY NAME & ADDRESS	PHONE

Applicant's Statement. Please Read Carefully

I understand that any misstatement, omission or misleading information given in my application or interview or in connection with other Saint Clare’s Health System record may result in the rejection of my application, the withdrawal of any offer of employment or my dismissal.

I authorize an investigation of all statements contained in this application for employment. I release from all liability and responsibility all persons and entities requesting or supplying information about any information provided on this applications, including my present employer. I also authorize Saint Clare’s Health System to conduct a check into my criminal conviction record.

I acknowledge that any offer of employment is contingent upon my satisfactorily completing the pre- placement medical examination and/or inquiry and a satisfactory background check. Such medical exam and/or inquiry may include a pre-placement drug test. My offer of employment may be revoked if it is determined that I cannot perform the essential job functions of the position with or without a reasonable accommodation, or if providing a reasonable accommodation would impose undue hardship on Saint Clare’s Health System, or if my employment would post a direct threat or substantial harm to myself or others.

I understand that if employed by Saint Clare’s Health System, both during and subsequent to my introductory period, I will be an employee at-will, which means that I can voluntarily end my employment or be terminated at any time without cause or notice. Any oral or written promises to the contrary are expressly disavowed and should no be relied upon by any prospective or present employee.

Saint Clare’s Health System is an equal opportunity employer and does not discriminate on the basis of race, creed, color, national origin, sex, age,

I accept the terms above.
I DO NOT accept the terms above.