* = Required Information
This facility is an equal opportunity employer. Federal and state laws prohibits discrimination of employment because of race, color, religion, age, sex, national origin or disabilities. No question on the application is asked for the purpose of limiting or excluding any applicant consideration for employment because of race, color, religion, age, sex, national origin or disabilities.
Full Time
Part Time
Temporary
If you need help filling out this application form or during any phase of the employment application process, please notify a member of the Human Resources Department and every effort will be made to accommodate your needs in a reasonable amount of time.
Position Desired
Name (Last, First, Middle) *
Phone Number *
Street Address
City *
State
ZIP
Social Security No.
Drivers License
Issuing State
Expiration Date
Have you ever been employed at this facility?
Yes No
Year
Department
Are you 18 years of age or older?
Yes No
Who referred you to us? Friend
Employee
Neighbor
Newspaper Ad
Other
Date Of Birth
Enter date you can start work
List any relatives employed at this facility
EDUCATION
Schools Name and Address of Institution Graduated Yes No Degree Received Average Grades Areas of Specialization
High School
Yes No
College
Yes No
Military Status

Veteran of US Armed Forces?
Yes No
Dates From
To      
Rank on Entering
Rank Attendance
Did you attend a Professional School?
Yes No
Type Location Period of Attendance
From To
Did you graduate?
Nursing From To
Yes No
Practical Nursing From To
Yes No
X-Ray From To
Yes No
Laboratory From To
Yes No
Other From To
Yes No
LICENSURE AND PROFESSIONAL ACTIVITIES
Licensed in (STATE) Registration Number Date Last Registered
Yes No
Yes No
EMPLOYMENT REFERENCES
List Most Recent Employer First
If currently employed may we contact your present employer?
Yes No
1. Place of Employment * Position Held
Address Name of Supervisor
City State Phone Number
Employment Date From To
Name used during employment Salary
Reason for leaving

2. Place of Employment * Position Held
Address Name of Supervisor
City State Phone Number
Employment Date From To
Name used during employment Salary
Reason for leaving

3. Place of Employment * Position Held
Address Name of Supervisor
City State Phone Number
Employment Date From To
Name used during employment Salary
Reason for leaving

4. Place of Employment * Position Held
Address Name of Supervisor
City State Phone Number
Employment Date From To
Name used during employment Salary
Reason for leaving
OTHER PERTINENT DATE
Have you been convicted of a crime other than a misdemeanor or summary offense?
Yes No
Year of conviction
Charges
Medical Professionals Only:
Have you ever been involved in a medical malpractice action?
Yes No
Explain
If employment is offered, can you submit a birth certificate, social security card, certificate of U.S, citizenship or verification of your legal right to work in the U.S?
Yes No
Employment will be contingent upon successful completion of a medical examination.
APPLICATION DISCLOSURE
PLEASE READ THIS STATEMENT CAREFULLY. SHOULD YOU HAVE ANY QUESTIONS, PLEASE SEEK ASSISTANCE BEFORE SIGNING THE APPLICATION. THIS COMPANY IS AN EQUAL OPPORTUNITY EMPLOYER AND SELECTS INDIVIDUALS BEST MATCHED FOR THE JOB BASED UPON JOB-RELATED QUALIFICATIONS REGARDLESS OF RACE, COLOR, CREED, SEX RELIGION, NATIONAL ORIGIN, AGE OR DISABILITY. I UNDERSTAND THAT ANY MISREPRESENTATION, MISINFORMATION OR INACCURACY OF THE STATEMENTS CONTAINED IN THIS APPLICATION MAY RESULT IN TERMINATION OF MY EMPLOYMENT OR WITHDRAWAL OF AN OFFER OF EMPLOYMENT. I AUTHORIZE THE COMPANY TO INVESTIGATE ALL INFORMATION AND REFERENCES AND TO OBTAIN ANY TRANSCRIPTS, RECORDS OR DOCUMENTS PERTAINING TO MY BACKGROUND AND BUSINESS EXPERIENCE AS REQUIRED TO ARRIVE AT AN EMPLOYMENT DECISION. I ALSO HEREBY RELEASE THE COMPANY, ITS OFFICERS, EMPLOYEES, REPRESENTATIVES OR AGENTS, FROM ANY AND ALL LIABILITY AND/OR DAMAGE INCURRED BY MYSELF IN OBTAINING SUCH INFORMATION.
I UNDERSTAND THAT IF I HAVE A PHYSICAL OR MENTAL IMPAIRMENT THAT SUBSTANTIALLY LIMITS ONE OR MORE OF MY MAJOR LIFE ACTIVITIES, OR A RECORD OF SUCH IMPAIRMENT, OR IF I OTHERWISE BELIEVE MYSELF TO BE COVERED BY THE AMERICANS WITH DISABILITIES ACT, I CAN ADVISE THE COMPANY AT ANYTIME DURING THE APPLICATION, INTERVIEW OR HIRING PROCESS ABOUT THE ACCOMMODATIONS THE COMPANY COULD MAKE TO ENABLE ME TO PERFORM THE ESSENTIAL FUNCTIONS OF THE JOB I AM SEEKING. I UNDERSTAND THAT SUBMISSION OF INFORMATION REGARDING REASONABLE ACCOMMODATION IS VOLUNTARY AND THAT MY REFUSAL TO PROVIDE IT WILL NOT SUBJECT ME TO ADVERSE TREATMENT IN THE EMPLOYMENT PROCESS, I FURTHER UNDERSTAND THAT INFORMATION OBTAINED BY THE COMPANY REGARDING MY DISABILITY WILL BE KEPT CONFIDENTIAL, EXCEPT THAT IF HIRED, (1) SUPERVISORS AND MANAGERS MAY BE INFORMED REGARDING RESTRICTIONS ON MY WORK OR DUTIES, AND REGARDING NECESSARY ACCOMMODATION, (2) FIRST AID AND SAFETY PERSONNEL MAY BE INFORMED WHEN AND TO THE EXTENT APPROPRIATE IF THE CONDITION MIGHT REQUIRE EMERGENCY TREATMENT AND (3) GOVERNMENT OFFICIALS INVESTIGATING COMPLIANCE WITH THE AMERICANS WITH DISABILITIES ACT MAY BE INFORMED. IN THIS CONNECTION, I AUTHORIZE ANY PHYSICIAN OR HOSPITAL TO RELEASE TO THE COMPANY ANY INFORMATION THAT MAY BE NECESSARY TO DETERMINE MY ABILITY TO PERFORM THE ESSENTIAL FUNCTIONS OF A JOB FOR WHICH I AM BEING CONSIDERED PRIOR TO EMPLOYMENT OR DURING EMPLOYMENT WITH THE COMPANY. IF OFFERED, EMPLOYMENT THE COMPANY MAY REQUIRE ME TO TAKE A PHYSICAL EXAMINATION AND DRUG AND ALCOHOL SCREEN THE RESULTS OF WHICH I AGREE CAN BE REPORTED TO THE COMPANY.
I HEREBY UNDERSTAND AND ACKNOWLEDGE THAT UNLESS OTHERWISE DEFINED BY APPLICABLE LAW, ANY EMPLOYMENT RELATION SUM WITH THIS ORGANIZATION IS OF AN "AT WILL" NATURE WHICH MEANS THAT THE EMPLOYEE MAY RESIGN AT ANYTIME AND THE EMPLOYER MAY DISCHARGE EMPLOYEE AT ANY TIME WITH OR WITHOUT CAUSE. IT IS FURTHER UNDERSTOOD THAT THIS - AT WILL STATUS IS "FULLY ACKNOWLEDGED IN WRITING BY AN AUTHORIZED EXECUTIVE OF THIS ORGANIZATION.
IF HIRED, I AGREE TO CONFORM TO THE RULES AND REGULATIONS OF THIS COMPANY AS ISSUED FROM TIME TO TIME.
Applicant Signature* Date