Employment Application

Transcription

1 SOURCE (Fields marked with an * are required) Advertisements please list: Employment Agency Name: College/University Recruiting please list: Internal Applicant: Current Employee Volunteer Corporate Website Direct Employee Referral Employee Name: Job Boards Source: Job Fair Which One? A recruiter called/ ed me Former Employee All Other: First Name* Middle Initial Last Name* Home Phone* Preferred phone number Cell/Mobile Phone* Preferred phone number * Work Phone* Preferred phone number Pager Number* Preferred phone number Check if you do not have an address Address* City/Town* State/Province/County* Zip/Postal Code* County Country*: United States of America Alternate Address* City/Town* State/Province/County* Zip/Postal Code* County Country*: United States of America Provision of the following information is voluntary and a refusal to provide such information will have no effect on the company s employment decision. Applicants are considered for positions without regard to race, color, religion, sex, national origin, sexual preference, age, marital status, medical condition, disability, or other legally protect status. Government agencies may require periodic reports on the sex, ethnicity, disability, and veteran status of applicants. This data is for analysis and affirmative action only and will be kept in a file separate from an employee s personal file. Sex: Male Female Race: Hispanic or Latino White (Not Hispanic or Latino) Black or African American (Not Hispanic or Latino) Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) American Indian or Alaskan Native (Not Hispanic or Latino) Asian (Not Hispanic or Latino) Decline to Identify ADDITIONAL INFORMATION Are you a U.S. citizen, or an alien legally authorized to work in the United States? Yes No Are you 18 years of age or older? Yes No Shift Preference*: Days Evenings Nights PRN/Temp Weekends No Preference/Any Shift Are you or have you ever been employed at LMHS? Yes No EDUCATION Have you been known by another name (i.e., due to marriage)? Yes No If Yes, please provide your former name(s) (first name and last name): High School: Did you graduate or receive a GED? Yes No College: Course of Study: Last Year Completed: Did you graduate? Yes No Degree earned: Certificate Associates Bachelors Masters PhD Other College or Trade School: Course of Study: Last Year Completed: Did you graduate? Yes No Degree earned: Certificate Associates Bachelors Masters PhD Other education: FM# 1008 Rev. 05/10 Page 1 of 5

2 LICENSING AND REGISTRATION (If you have licensure or registration (or eligible), please complete the section below. If not, please skip to the next section). Are you licensed, certified or eligible to be licensed for the job in which you are applying? Yes No Please indicate your current and valid profession licenses/certifications and issuing state below (i.e Registered Nurse, FL). Military Service* Have you ever served in the Armed Forces? From: To: Yes No If applicable, include type of discharge: (You will be asked to provide a copy of the DD Form 214, Certificate of Release or Discharge from active duty) EMPLOYMENT HISTORY Please include your work history for the past 10 years (if applicable). This is important to help us determine your match for this job and related compensation. CURRENT OR NOTE: If you do not have any employment history or volunteer work to enter in the fields below, please enter, Not Applicable (N/A) in the required fields below. FM# 1008 Rev. 05/10 Page 2 of 5

3 EMPLOYMENT HISTORY continued May we contact your current or past employers? Yes No If, not, please indicate below which ones you do not wish us to contact: FM# 1008 Rev. 05/10 Page 3 of 5

4 PROFESSIONAL/EDUCATIONAL REFERENCES Name [1]: Name [2]: Name [3]: Name [4]: RESUME Please attach your resume at the back of this application. FM# 1008 Rev. 05/10 Page 4 of 5

5 CRIMINAL HISTORY Note: Conviction means you were found guilty by a judge, a jury, by pleading "no contest," or by pleading guilty in court. A conviction may have taken place even if you did not pay a fine or spend any time in jail or prison. A conviction will not automatically disqualify you from employment. *Have you ever been convicted of a felony or a misdemeanor (including, but not limited to such offenses as DUI, battery, theft, writing worthless checks, suspended license, etc.)? Yes No *Have you ever pled nolo contendere or pled guilty to a crime, which is a felony or a misdemeanor (including, but not limited to such offenses as DUI, battery, theft, writing worthless checks, suspended license, etc.)? Yes No *Have you ever had the adjudication of guilt withheld to a crime, which is a felony or a misdemeanor (including, but not limited to such offenses as DUI, battery, theft, writing worthless checks, suspended license, etc.)?* Yes No Please Read Carefully: (please check box)* I certify that the answers given by me to the questions and statements on Lee Memorial Health System's (LMHS) application/resume are true and correct without omissions of any kind whatsoever. I understand that all information I provide in this application is subject to verification on a routine basis as part of the hiring and employment process. I have reviewed the job description for the position to which I am applying and certify that I am able to perform the essential functions of the job (including physical and mental requirements) with or without a reasonable accommodation. I understand that LMHS observes a workplace free of drugs, alcohol, and tobacco use. I understand that job applicants are required to submit to a drug test and fitness for duty screening following a conditional offer of employment.i understand that if employed, falsified statements, answers or omissions will be considered sufficient cause for termination, even if discovered at a later date. Release for References: (please check box)* In consideration of an application for employment, I hereby authorize Lee Memorial Health System either acting on its own or through a third party, to conduct research and compile a report regarding my background including, but not limited to, information about prior employment, education, consumer credit history, criminal record, and general public records history. I hereby authorize the use of an investigative consumer report and understand that such an investigative consumer report may contain information about my background, mode of living, character and personal reputation. I also understand that I am entitled to receive a written disclosure of the nature and scope of the investigative report, and a summary of my rights under the Fair Credit Reporting Act, as amended, if I request this information in writing. I hereby authorize, without reservation, any person, agency or other entity contacted by LMHS or LMHS' agents to furnish the above mentioned information. I hereby release LMHS, its respective officers, directors, employees and agents, and all persons, agencies, and entities providing information or reports about me from any and all liability arising out of the release of any such information or reports. I acknowledge and understand that all information and reports collected by LMHS may be used in evaluating my employment application and fitness for employment. I have read and fully understand the above statements, and acknowledge this by clicking the box and submitting my application/resume. Applicant Signature: Date: Lee Memorial Health System is an equal opportunity employer, and we support a drug-free/smoke-free workplace. Pre-employment drug testing is required. Preference may be given to individuals who exceed minimum job requirements. FM# 1008 Rev. 05/10 Page 5 of 5