Employment Application

Date of Application (*)

Date Available for Employment (*)


To Applicant: We appreciate your interest in our organization and assure you that we are sincerely interested in your qualifications. A clear understanding of your background and work history will aid us in placing you in the position that best meets your qualifications and may assist us in possible future upgrading.

This facility is an equal opportunity employer. Employment, educational opportunities, and promotions in all job classifications are without regard to race, color, creed, sex, age, national origin, religion, disability or military status.


Instructions to Applicant

1. You must fully and accurately complete the Application for Employment. Incomplete applications will not be considered.

2. The Application for Employment will be considered inactive after 90 days. If you wish to be considered after that time, you must complete


Your Full Name (*)

Street Address (*)

City (*)

Zip Code (*)

Your Email (*)

Home Phone (*)

Cell Phone (*)

Position(s) Applied For (*)

Full TimePart TimeOn-CallTemporaryStudent/Shadow

Desired Rate of Pay (*)

Which Shifts Are You Willing to Work? (*)
DaysEveningsNightsHolidays


Education/Training

Name of your High School

Diploma Received
YesNo

Years Completed
9101112

Name of your College/University

Degree/Area of Study at your College

Years Completed
1234

Name of your Trade/Tech School

Degree/Area of Study at your Trade/Tech School

Years Completed
1234

Name of your Graduate School

Degree/Area of Study at your Graduate School

Graduate Education Credits/Years


Professional

Current Professional License Type

Year

State

License Number

Seminars/Other:

Please describe any specialized training, internships, apprenticeships, skills or extra-curricular activities you feel qualifies you for the position :


Employment History

List Most Recent Employer First

Employer: (*)

Employer Address: (*)

May we contact?: (*)
YesNo

Dates Employed: (*)

From: (*)

To: (*)

Duties/Functions: (*)

Telephone: (*)

Supervisor: (*)

Hourly Rate/Salary: (*)

Reason for Leaving: (*)


Employer:

Employer Address:

May we contact?:
YesNo

Dates Employed:

From:

To:

Duties/Functions:

Telephone:

Supervisor:

Hourly Rate/Salary:

Reason for Leaving:


Employer:

Employer Address:

May we contact?:
YesNo

Dates Employed:

From:

To:

Duties/Functions:

Telephone:

Supervisor:

Hourly Rate/Salary:

Reason for Leaving:


Employer:

Employer Address:

May we contact?:
YesNo

Dates Employed:

From:

To:

Duties/Functions:

Telephone:

Supervisor:

Hourly Rate/Salary:

Reason for Leaving:


Employer:

Employer Address:

May we contact?:
YesNo

Dates Employed:

From:

To:

Duties/Functions:

Telephone:

Supervisor:

Hourly Rate/Salary:

Reason for Leaving:


For reference purposes, is your educational or employment history listed under another name? (*)
YesNo

If so, what?

Explain any unemployment periods of two months or more.


References

Please list three references with name, address and phone number.

Name (*)

Occupation (*)

Address (*)

Phone (*)


Name (*)

Occupation (*)

Address (*)

Phone (*)


Name (*)

Occupation (*)

Address (*)

Phone (*)


General Information

Please indicate if you speak, read or write any other languages and how well.


Who referred you to this facility?

EmployeeFriend/RelativeWalk-InAdvertisement

If so, who or where?

Have you been employed with this hospital or clinic before?

YesNo

If yes, when?

Are you over 18?

YesNo

Can you, if hired, sumbmit verification of your legal right to work in the U.S.?

YesNo

If hired, you will be required to submit documents sufficient to establish employment authorization and identity in compliance with the Immigration Reform and Control Act of 1986.

Do you have a record of founded child or dependent adult abuse?

YesNo

Have you ever been convicted of a crime in this state or any other state?

YesNo

If yes, please explain:

Have you ever been excluded from providing patient care to those receiving Medicare or other federally funded?

YesNo

If yes, please explain:

(Note: No applicant will be denied employment solely on the grounds of a conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)


Document Terms and Conditions

Please Read and Check Each Paragraph Below:

I hereby authorize Hawarden Regional Healthcare to thoroughly investigate my references, work records, education and other matters related to my suitability for employment and, further, authorize my current and former employers to disclose the company any and all letters, reports and other information pertaining to my employment with them, without giving me prior notice of such disclosure. In addition, I hereby release Hawarden Regional Healthcare, my current and former employers, and all other persons corporations, partnerships, and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

Check here if you accept these terms.

I understand that if offered employment, the offer may be contingent on my passing a Post Offer physical and drug screen. By signing this application, I voluntarily agree to submit to a Post Offer physical and drug screen upon request. I understand that failure to pass the physical and drug screen will result in withdrawal of the employment offer.

Check here if you accept these terms.

I understand that nothing contained in the application or conveyed to me during any interview, which may be granted, is not intended to create an employment contract, implied or explicit, between me and Hawarden Regional Healthcare. In addition, I understand and agree that if I am employed, my employment relationship with Hawarden Regional Healthcare is strictly voluntary and at our mutual will. I understand that if employed, my employment is for no definite period and may be terminated at any time, with or without prior notice, with or without cause or reason, at the option of either myself or Hawarden Regional Healthcare, and that no promises or representations contrary to the forgoing are binding on Hawarden Regional Healthcare unless made in writing ans signed jointly by the Administrator and myself.

Check here if you accept these terms.

I understand and agree that any future changes in my title, duties, compensation, working conditions, and/or Hawarden Regional Healthcare benefits, policies and procedures will not alter our at-will and arbitration agreements.

Check here if you accept these terms.

I understand that if offered employment, I will, as a condition of my employment, be required to submit proof of my identity and legal right to work in the United States on my first day of employment.

Check here if you accept these terms.

If the position applied for requires driving in the course of work, I understand that I will be required to possess a current and valid state driver's license and understand that I may be required to provide a copy of my official driving record and proof of insurance.

Check here if you accept these terms.

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

Check here if you accept these terms.


After submitting our online application please fill out the Voluntary EEO Identification for applicants below.

Qualified applicants are considered for employment without regard to race, religion, sex, national origin, age, marital status, sexual orientation, veteran status, disability, or other protected characteristic.

This employer is subject to certain governmental record keeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, we invite qualified applicants to voluntarily self-identify their race or ethnicity, gender, and veteran status (if applicable). Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.

Your Name (*)

Street Address (*)

City (*)

State (*)

Zip Code (*)

Gender (*)
MaleFemale

Please select only one of the choices below:
(Explanations of these categories are listed below on this form)

Ethnicity (*)

Race (*)

SPECIAL NOTICE TO QUALIFIED VETERANS:
Regulations issued by the U.S. Department of Labor with respect to Vietnam Era veterans and other protected veterans require that federal contractors provide an opportunity for self-identification to candidates seeking employment. Such self-identification is submitted on a voluntary and confidential basis for use only in accordance with regulations, and without subjecting the individual to adverse treatment.

Veteran Classification (Explanations of these categories are listed below on this form)

Your Signature (*)

Date (*)

AN EQUAL OPPORTUNITY EMPLOYER

EXPLANATION OF THE CATEGORIES:

Hispanic or Latino (White Race only): A person of Mexican, Puerto Rican, Cuban, Central or South America or other Spanish culture or origin, and of the White Race.

Hispanic or Latino (all other races): A person of Mexican, Puerto Rican, Cuban, Central or South America or other Spanish culture or origin, and of any race other than White.

White: A person having origins in any of the original peoples of Europe, North Africa or the Middle East.

Black (or African American): A person having origins in any of the black racial groups of Africa.

Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

American Indian or Alaskan Native: Persons having origins in any of the original peoples of North America and South America (including Central America) and who maintains tribal affiliation or community attachment.

Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Two or More Races (Not Hispanic or Latino)- All persons who identify with more than one of the above five races.

Recently Separated Veteran: any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval or air service.

Armed Forces Service Medal Veteran :any veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Other Protected Veteran: a veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized, under the laws administered by the Department of Defense.