Type of employment desired Full-Time (40 hours/week)
Part-Time
Temporary
Last Name *
First Name *
Middle Name
Present Address *
City
State
Zip Code
Home Phone *
123-456-7890
If you cannot be reached at the above address/telephone number, where may we contact you?
Are you at least 16 years of age?
Yes No
Have you ever been employed here before?
Yes No
Date available for work
MM/DD/YYYY
Number of hours per week you will consider:
Minimum Hours
Maximum Hours
Are there any hours of the day or days of the week that you cannot work? If so please list
Employment History
List your last three employers, assignments or volunteer activities starting with your most recent position:
Employer's Name
From Mo./Yr.
To Mo./Yr.
Address and Phone Number
Job Title and/or Duties
Reason For Leaving
Supervisor
Rate of Pay:
May we contact this Employer?
Yes
No
Supervisor
Rate of Pay:
May we contact this Employer?
Yes
No
Supervisor
Rate of Pay:
May we contact this Employer?
Yes
No
List any other experience that you believe would be helpful
Are you legally eligible for employment in this country?
Yes No
(Proof of U.S. citizenship or immigration status will be required upon employment.)
Have you ever, since the age of 18, been convicted of a misdemeanor or a felony?
Yes No
If yes, please explain
*Conviction does not necessarily disqualify you from employment. Each conviction will be judged on its own merit with respect to time, circumstances and seriousness.
Military Service
In what branch of the Armed Forces did you serve?
From
To
Highest Rank
What kind of education or training did you receive?
Education
Type
City/State
Last year completed
Dates
Graduated
Degree/Major
High School/G.E.D.
Yes No
College
Yes No
Graduate School
Yes No
Health Care Professional Licenses And/Or Certification
Type
State Issued
Date
Number
References
Please do not list friends and relatives
Name
Occupation
Years Known
Telephone
Relationship
An Equal Opportunity Employer
River's Edge Hospital & Clinic does not discriminate against employees on the grounds of race, color, religion, age, sex, disability, naitonal origin, ancestry, affectional preference or marital status.
The following information is needed to determine how effective our recruiting efforts are in the community and other areas; to validate our selection procedures and, to meet the reporting requirements of the Federal Law,
the answers to these questions are optional and will not be placed in your personnel file nor will they be given to any person involved in making a hiring or promotional decision.
Sex Male
Female
Ethnic Group
American Indian
Asian
Black
Hispanic
White
Other
Military Status
Active Reserves
Inactive Reserves
None
Other Veteran
Retired
Vietnam Veteran
Highest Education
Some High School
High School Graduate or equivalent
Some College
Community College/Technical School Grad
Any Post-Graduate Work
Age
Under 18
18-25
26-39
40 and over
How did you learn about ths job?
Want Ad
Agency
Employee/Volunteer referral
College Recruiter
I am current employee
I am a former employee
Job Fair/Open House
Job Posting
Phone Inquiry
Unsolicited
Walk-In
Other
Disable Veteran
Yes No
I do not wish to give any information
Agreement - Please read thoroughly and sign below
I hereby authorize the investigation of my background including all the information contained in this application and information provided in the interview.
I understand that misrepresentation or omission of information in connection with my application and or interview will be sufficient cause, in and of itself, for rejection or dismissal whenever discovered.
I understand that emploment is subject to satisfactory completion of River's Edge Hospital & Clinic pre-employment investigation which includes, but is not limited to satisfactory
reference checks, satisfactory completion of a pre-placement assessment, which includes a drug test, after an offer of employment has been made, but prior to commencement of employment and a criminal background study.
I understand that if I am hired by River's Edge Hospital & Clinic, my employment will be for an indefinite period of time and will be "at-will", which means that either
I or River's Edge Hospital & Clinic may terminate the employment relationship at any time and for any or no reason. Finally, I also understand that while River's Edge Hospital & Clinic supposrts current
policies and benefits, it retains the right to change them at any time, with or without notice to me.
I have read and understand the statements in the paragraph above. By signing here, I am also verifying information on my resume.
