Professional Development Program

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1 NAME/Last, First, Middle: Semester and Year Applying: Date: Professional Development Program Student Application Overlook Medical Center Department of Human Resources 99 Beauvoir Avenue Summit, New Jersey Attn: Diane Schneider, RN Atlantic Health System is an equal opportunity employer and will not discriminate on the basis of race, religion, color, national origin, age, sex, disability or any other legally protected status. Overlook Medical Center will make reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation would impose an undue hardship on the operation of the hospital.

2 Please Print Clearly Personal Name: Last First Middle Initial Home Address: Street Apt./No. City State Zip Code Telephone Number: Cell - ( ) Home - ( ) Address: Home - School - Required information for students under age 21: ( ) Name of Parent, Spouse or Legal Guardian Telephone Number Relationship: o Father o Mother o Other Explain if Other Name of School: School Address: Street City State Zip Code Telephone Number of Bursar s Office: ( ) Field of Study: Are you presently enrolled at the school listed above? o Yes o No If no, have you been ACCEPTED at that school? o Yes o No You are/will be o Full Time Student o Part Time Student o Accelerated Track Expected date of graduation: Month Year How were you referred to this program? Have you been employed by Atlantic Health System? o Yes o No If yes, when: If yes, briefly describe your duties, department and location while employed at Atlantic Health System:

3 1. Have you received Atlantic Health System Tuition Reimbursement? o Yes o No If yes, explain when, how much and for what purpose you used or will be using the funds. 2. Have you received an Overlook Medical Center Auxiliary Scholarship? o Yes o No If yes, explain when, how much and for what purpose you used or will be using the funds. 3. Are you receiving any other financial aid or student loans? o Yes o No If yes, explain: Education (Please provide Official Transcripts from each institution.) Name and Address of School Course of Study Check Last Year Completed GPA High School (Needed if graduation has been within the past 5 yrs.) College College OTHER Business College, Other Special Courses (Include Special Military Training, Post Graduate and Nursing) List References (Include one nursing instructor; no relatives or friends; must be different from letters of recommendation.) Name Title Company Name & Address Telephone

4 Are you a U.S. Citizen? o Yes o No If no, can you provide documentation that you can work in the U.S.? o Yes o No Are you an alien who is authorized to work in the U.S.? o Yes o No Did you serve in the U.S. Armed Services? o Yes o No If yes, what branch? Have you been convicted of or pled guilty to a crime or criminal offense, other than a minor traffic violation, which has not been expunged or sealed by a court? o Yes o No An application form only tells part of the story. We need the following included with this application: Here s your chance to tell us about yourself. Please write a one page essay to tell us why you have chosen a particular health care career. A current resume, highlighting any previous health care experience. 2 letters of recommendation (professional letterhead required) from instructors or supervisors. For nursing students, one letter must be from a nursing instructor. Letters may not be from those listed as references. Atlantic Health System employees: One letter may be from your current manager. I hereby affirm that the information provided in this application (and accompanying resume) is true and complete. I understand that any false or misleading representations or omissions may disqualify me from further consideration if discovered at a later date. I hereby authorize persons, school, my current employer, (if applicable) and previous employers and organizations named in this application (and accompanying resume, if any) to provide this facility and all affiliates with any relevant information regarding a decision, and I release all such persons from any liability regarding the provision or use of such information. Date: Signature:

5 Written Disclosure to Applicant and Consent to Request Consumer Report Information I understand that Atlantic Health System will utilize the services of a consumer reporting agency as part of the procedure for processing my application for enrollment in the Professional Development Program at Overlook Medical Center. I also understand that if my application for enrollment in this program is granted, Atlantic Health System may obtain further information through subsequent investigations by a consumer reporting agency so as to update, renew or extend my employment. I understand a consumer reporting agency s investigation may include obtaining information covering up to the last seven years regarding my credit background, references, character, past employment, work habits, education, general reputation, personal characteristics, mode of living, civil judgments and liens, as well as any information about my criminal conviction background consistent with federal and state law. I understand such information may be obtained by direct or indirect contact with former employers, schools, financial institutions, landlords and public agencies or other persons who may have such knowledge. I also understand that before I am denied enrollment in the aforementioned Professional Development Program, based in whole or in part, on information obtained in the report, I will be provided a copy of the report and a description in writing of my rights under the Fair Credit Reporting Act. I understand if I disagree with the accuracy of any information in the report, I must notify Atlantic Health System within two days of my receipt of the report. If I notify Atlantic Health System within two days of receipt of the report that I am challenging, Atlantic Health System will not make a final decision on my enrollment status until after I have had a reasonable opportunity to address the information contained in the report. I hereby consent to this investigation and authorize Atlantic Health System to procure a report on my background as stated above from a consumer reporting agency. (Signature of Applicant) (Date) HR

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