Application for Employment

It is the policy of this facility to provide equal opportunity to persons regardless of race, religion, age, gender, disability or any other classification in accordance with federal, state and local statutes, regulations and ordinances.

Applicant Name (Please Give Complete Name)
  
Are you at least 18 years old? Yes    No
Home Phone:
Email Address:
Present Address (Include City, State, Zip Code):
  
Previous Address (If at present address less than 12 months):
  
Current Open Position(s) for Which You Are Applying:

   1)

   2)

   3)

Type of Position:
Per Diem
Full Time
Part Time
Pool
PRN
Temporary
Shift:
Day
Weekend
Night
Salary Requirement:
Are You Willing to Travel? Yes    No
Are You Willing to Relocate? Yes    No
Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?
Yes    No
If overtime work is required periodically, does this pose a problem for you?
Yes    No
Date Available For Work:
Are You Legally Authorized to Work in the U.S.?
Yes    No
Have you ever worked at this facility or a facility associated with Signature?
Yes    No
If yes, what facility?
Are you related to another facility employee? Yes    No
How did you learn about this position?
State Employment Commission
Agency
Job Listing
Current Employee
Other

Ad
School
Job Line
Internet
Are you able to perform the essential, job related functions of the position for which you are applying with or without accommodations?
Yes    No
Have you been convicted of a crime and/or released from confinement following a conviction for any criminal offense?
Yes    No    Arrest or charges that have been expunged need not be disclosed.
If yes, give date, place and nature of each such conviction.
  
Are you presently charged with any violation of the law?
Yes    No
If yes, give date, place and nature of each such charge.
  
Are you currently excluded from participation in any federally funded healthcare program - including Medicare and Medicaid - and are you aware of any potential exclusion from a federally funded health program?
Yes    No

Educational History

High School/GED
School Name, City, State:
  

Last Year Attended:
9   10   11   12

Graduated/GED? Yes    No
Degree or certificate:
 
College
School Name, City, State:
  

Last Year Attended:
1   2   3   4

Graduated? Yes    No
Degree or certificate:
 
College
School Name, City, State:
  

Last Year Attended:
1   2   3   4

Graduated? Yes    No
Degree or certificate:
 
Graduate School
School Name, City, State:
  

Last Year Attended:
1   2   3   4

Graduated? Yes    No
Degree or certificate:
 
Other
School Name, City, State:
  

From (Year):

To (Year):

Degree or certificate:
 
Other
School Name, City, State:
  

From (Year):

To (Year):

Degree or certificate:
List any professional licenses, registration or certification you possess (Include Drivers License, if applicable)
Type State Issued Expiration Number
1)
2)
3)
4)
5)
Has your license(s) in this state or another state been suspended, limited, revoked, or under investigation?
Yes    No
Please explain:
Clerical or other skills applicable to the position for which you are applying
Typing   ( wpm) PBX
Proficient in Software:
  
Business machines and/or equipment you can operate:
  
Other:
  

Employment History

Please provide a minimum of the most recent 10 years employment history including any period of unemployment.
 
Current or Most Recent
Company Name and Address:
  

From (mm/yy):

To (mm/yy):

Salary: $

Phone No.:    May we contact them? Yes    No
Job Title:
Other reference with this employer:
Nature of Duties:
  
Immediate Supervisor:
Name while employed:
Reason for leaving:
 
1st Previous
Company Name and Address:
  

From (mm/yy):

To (mm/yy):

Salary: $

Phone No.:    May we contact them? Yes    No
Job Title:
Other reference with this employer:
Nature of Duties:
  
Immediate Supervisor:
Name while employed:
Reason for leaving:
 
2nd Previous
Company Name and Address:
  

From (mm/yy):

To (mm/yy):

Salary: $

Phone No.:    May we contact them? Yes    No
Job Title:
Other reference with this employer:
Nature of Duties:
  
Immediate Supervisor:
Name while employed:
Reason for leaving:
 
3rd Previous
Company Name and Address:
  

From (mm/yy):

To (mm/yy):

Salary: $

Phone No.:    May we contact them? Yes    No
Job Title:
Other reference with this employer:
Nature of Duties:
  
Immediate Supervisor:
Name while employed:
Reason for leaving:
 

Professional References (Other than Relatives)

Give two references who have good knowledge of your work.
1. Name: Phone:
   Position: No. Years Known:
   Address:
 
2. Name: Phone:
   Position: No. Years Known:
   Address:

Please Review and Check Where Indicated.

In making application for employment:

I certified that the information in this application is true and complete for all practical purposes. It may be verified by the facility or any affiliate. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the facility or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.

I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable. If such an investigative report is made, I understand that I will receive notice that such report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.

I UNDERSTAND AND AGREE THAT ANY EMPLOYEE HANDBOOK WHICH I MAY RECEIVE WILL NOT CONSTITUTE AN EMPLOYMENT CONTRACT, BUT WILL BE MERELY A GRATUITOUS STATEMENT OF FACILITY POLICIES.

I understand that the facility reserves the right to require its employees to submit to blood tests or urinalyses for alcohol or drug screens, or to allow inspection of bags (including purses or briefcases) or parcels brought into or taken out of the facility. I understand that refusal to submit to a urinalysis, blood test or search, when requested to do so, may result in termination of my employment.

Compliance with this facility's Substance Abuse Policy is a condition of employment. This facility requires that every newly hired employee be free of alcohol or drug abuse. Each offer of employment is contingent upon successfully completing a urinalysis test/screen for alcohol and drugs in accordance with facility policy. Continued employment is also contingent upon compliance with the facility's Alcohol and Drug Abuse Policy.

I UNDERSTAND AND AGREE THAT IF I AM OFFERED EMPLOYMENT BY THE FACILITY, MY EMPLOYMENT WILL BE FOR NO DEFINITE TERM AND THAT EITHER I, OR THE FACILITY WILL HAVE THE RIGHT TO TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE. I ALSO UNDERSTAND THAT THIS STATUS CAN ONLY BE ALTERED BY A WRITTEN CONTRACT OF EMPLOYMENT WHICH IS SPECIFIC AS TO ALL MATERIAL TERMS AND IS SIGNED BY ME AND THE ADMINISTRATOR OF THE FACILITY.

Release:
I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my licensure status and my licensure history.

I have read and understand these conditions of employment.