Employment Application

In considering your application for employment, the facility may conduct a detailed and thorough investigation which may include but is not limited to a criminal record check, interviews or inquiries of prior employers, coworkers, acquaintances, relatives or friends.

Personal

Last Name

First Name

Middle Name

Present Address

City

State

Zip

Permanent Address

City

State

Zip

Any Previous Names

If yes, identify all names including Maiden name

Social Security #

Home Phone

Contact Phone

Best Time to Contact

Date Available

Applying For

Position Applied For

Salary Desired

How Were You Referred to Us

Relatives/Friends Employed Here

Name

Dept

Relationship

Have you ever been employed by this facility

Are you 18 years of age or older

Are you a U.S. citizen or an alien legally authorized to work in the United States

Would You Consider Working:

Weekend/Holidays

Rotating Shifts

On Call

Any Shift

Shift Preference

Days Evenings Nights

Long Range Occupational Goals

Have you ever been convicted of, or plead guilty to, a crime other than misdemeanor traffic violations?

Yes No

If Yes, which state(s), and explain

(You are not required to disclose any SEALED or EXPUNGED criminal records.)

Have you ever been involved in the substantiated abuse or neglect of children or adults under the laws of this or any other state of the united states?

Yes No

If Yes, which state(s), and explain

Have you been sanctioned, cited, reported, or excluded from participation in medicare, medicaid, or any other healthcare related law or regulation?

Yes No

If Yes, explain

If your answer is Yes to any of the above, you will not be automatically disqualified from employment consideration, except as required by state or federal law.

Education / Skills

High School

High School Name

Address

Course of Study

Last Year Completed

Did You Graduate

Diploma or Degree

College

College Name

Address

Course of Study

Last Year Completed

Did You Graduate

Diploma or Degree

College

College Name

Address

Course of Study

Last Year Completed

Did You Graduate

Diploma or Degree

Other Business College or Special Courses: (Include Special Military Training, Post Graduate and Nursing)

Area(s) of Specialization or Major Interest:

List Office Skills Including Computer/Software Experience:

List Health Care, Business, or Industrial Equipment Operated:

Word Processing: (approx. Wpm)

Professional License 1

Type

Number

State

Date

Status

Currently Licensed Eligible for License Currently Registered Eligible for Registration

License or Registration Ever Suspended, Revoked or on Probation

Yes No

If Yes, Explain

Professional License 2

Type

Number

State

Date

Status

Currently Licensed Eligible for License Currently Registered Eligible for Registration

License or Registration Ever Suspended, Revoked or on Probation

Yes No

If Yes, Explain

Professional Certification 1

Type

State

Date

Status

Professional Certification 2

Type

State

Date

Status

Briefly describe duties and skills acquired through military or volunteer service: (include dates)

Previous Experience

Provide Information Regarding Previous Employment Beginning With Most Recent Employer.

Employer Recent

Address

Phone

Supervisor

From (Mo/Yr)

To (Mo/Yr)

Job Title

Duties

Reason for Leaving

May We Contact your Current Employer

Yes No

Employer

Address

Phone

Supervisor

From (Mo/Yr)

To (Mo/Yr)

Job Title

Duties

Reason for Leaving

Employer

Address

Phone

Supervisor

From (Mo/Yr)

To (Mo/Yr)

Job Title

Duties

Reason for Leaving

Employer

Address

Phone

Supervisor

From (Mo/Yr)

To (Mo/Yr)

Job Title

Duties

Reason for Leaving

Please Identify and Explain Any Gaps in Employment Longer Than Three (3) Months:

Language

Do Not Complete Unless Requested

Language 1

Speak

Read

Write

Language 2

Speak

Read

Write

References

At least 3 References Who Are Not Relatives

Name & Relationship

Title

Company & Address

Phone

Name & Relationship

Title

Company & Address

Phone

Name & Relationship

Title

Company & Address

Phone

Standards of Behavior

Thank you for your interest in joining our hospital team!

We have a strong mission of providing excellence in health care and promoting lifelong wellness in the communities we serve. As hospital staff, we have a wonderful opportunity to practice excellence in customer service. We take pride in meeting and surpassing the expectations of patients, families, physicians, and each other every day. This means we support and treat each other with a high level of respect, dignity, and service.

With this in mind, our staff have developed standards of behavior to guide us in achieving and maintaining service excellence. Our goal is to choose staff that will be able to follow and exemplify these standards.

We have attached a copy of the standards of behavior. By signing the application you are agreeing to follow the standards of behavior and understand that this is a condition of employment at Hillsboro Area Hospital.

Download the Standards of Behavior Document.

Signature

Carefully Read This Section Prior To Providing Signature Below

I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete. I understand that any false or misleading representations or omissions made on the application or during the hiring process may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date.

I understand that employment may be conditioned upon successfully passing a medical examination and that I may be required to satisfactorily complete a drug screening as a condition of employment.

I hereby authorize persons, schools, my current employer (if applicable) and previous employers and other organizations to provide this facility and its affiliates with any requested information regarding my application or suitability for employment, and I completely release all such persons or entities from any and all liability related to the providing or use of such information.

I understand that my employment is at-will which means that I may terminate the employment relationship at any time and for any reason with or without notice, and that the facility has the same right. I understand that no one has the authority to enter into any agreement contrary to the preceding sentence, except for a written agreement signed by an administrative representative of this facility and notarized. I have read and agree to follow the attached Standard of Behavior

Date

Signature (type name)