Hospital Job Application Form – Fill Out and Use This PDF

EMPLOYMENT APPLICATION CALAIS REGIONAL HOSPITAL, 24 Hospital Lane, Calais ME 04619

hrd@calaishospital.org

Today’s Date:

Social Security Number:

Date of birth if under age 18:

Last Name

First Name

Nickname

Full Middle Name

Message Telephone Number:

Address:

Street

City

State

Zip

Telephone Number:

Email:

Position Applied for:

Are you willing to work

( ) Full Time

( ) Per Diem

( ) Summer

(Check all that apply)

( ) Part Time

( ) Temporary

Date Available to Start Work:

List days you are available to work:

List all hours you are available to work:

Are you eligible to be lawfully employed in the U.S.?

( ) Yes

( ) No

Do you realize that it

may be necessary for you

to work

Proof of citizenship or immigration status will be required upon employment.

weekends, holidays or rotation shift?

( ) Yes

( ) No

Education Circle the highest grade completed:

Grade School: 1 2 3 4 5 6 7 8

High School 9 10 11 12

College: 13 14 15 16 17

School Attended

City

State

Zip

Course of Study

Did you

GED, Diploma, or Degree

graduate?

(Attach copy )

High School

College

Technical

Employment Record - List last 4 employers, beginning with most recent. Note: do not write “see resume”

Employer Name:___________________

Dates employed:

______ to ________

Supervisor: _______________________

Address: _________________________

Position and Duties:________________

Reason for leaving__________________

City, State, Zip: ____________________

________________________________

_________________________________

Phone:

Salary:

May we check references?

( ) Yes

( ) No

Employer Name:___________________

Dates employed:

______ to ________

Supervisor: _______________________

Address: _________________________

Position and Duties:________________

Reason for leaving__________________

City, State, Zip: ____________________

________________________________

_________________________________

Phone:

Salary:

May we check references?

( ) Yes

( ) No

Employer Name:___________________

Dates employed:

______ to ________

Supervisor: _______________________

Address: _________________________

Position and Duties:________________

Reason for leaving__________________

City, State, Zip: ____________________

________________________________

_________________________________

Phone:

Salary:

May we check references?

( ) Yes

( ) No

Employer Name:___________________

Dates employed:

______ to ________

Supervisor: _______________________

Address: _________________________

Position and Duties:________________

Reason for leaving__________________

City, State, Zip: ____________________

________________________________

_____________________________________

Phone: _____________________

Salary:

May we check references?

( ) Yes

( ) No

ALL APPLICANTS COMPLETE:

Keyboarding __Yes __No Speed:_____WPM

Number of Years of study?____

Computer Skills: __Word __Excel __Access __Power Point __Fax __Internet __Email __Scanner

__Other

NURSING & HOME HEALTH APPLICATIONS COMPLETE:

Check areas you have experience or special interest in:

( ) Inpatient & Special Care ( ) ED ( ) Inpatient & Obstetrics

( ) Physician Practices

(

) Home Health

( ) Surgery ( ) PACU

( ) Other, please specify:_______________________________.

( ) Maine nursing license number is: _______Expires:______ Copy is Attached. ( ) I

applied for my Maine license on (date): ___

( ) I am a Certified Nursing Assistant and am on the Maine CNA Registry. A copy of my CNA certificate is attached.

( ) I applied to the Maine CNA Registry on (date):__________

NON-NURSING REGISTERED/CERTIFIED APPLICANTS TO COMPLETE:

Registrations and/or certifications: (attach copies)

Agency:__________________________ Number:_______________________ Expiration:___________________

Agency:__________________________ Number:_______________________ Expiration:______________________.

PERSONAL REFERENCES

Do NOT list relatives, or repeat names already listed on other side. Include complete address and telephone numbers.

Name _______________________________________________	Name _______________________________________________
Street_______________________________________________	Street _______________________________________________
City ______________________State _________ Zip _________	City ______________________State _________ Zip _________
Occupation: _______________ Area Code _____ Tel. _______	Occupation: _______________ Area Code _____ Tel. _______
Name _______________________________________________	Name _______________________________________________
Street _______________________________________________	Street Address _______________________________________
City ______________________State _________ Zip _________	City ______________________State _________ Zip _________
Occupation: _______________ Area Code _____ Tel. _______	Occupation: _______________ Area Code _____ Tel. _______
If you have ever been known by a different first or last name, please list	them here:__________________________________________________

List the name and relationship of any relatives who are currently employed by CRH:__________________________________________________

List any skills or special training you may have that might qualify you for a position in our Hospital: ___________________________________

_________________________________________________________________________________________________________________________

Have you ever been convicted of a crime, other than a minor traffic offense? ( ) Yes ( ) No If yes, please explain:

__________________________________________________________________________________________________________________________

Have you ever been employed by the State of Maine? ( ) Yes ( ) No

During the 12 months preceding this application, were you employed by the Medicare intermediary or carrier? ( ) Yes ( ) No

Have you ever been convicted, involved in, or currently in a pending resolution of any criminal offense related to health care, or listed as disbarred,

excluded or otherwise ineligible for participation in Federal healthcare programs? ( ) Yes ( ) No. If yes, explain:___

__________________________________________________________________________________________________________________________

If previously employed at Calais Regional Hospital, please give dates: ______________________________________________________________

Do you object to the release of information from your personal record to prospective employers?	( ) Yes	( ) No
Can you perform the essential functions of the job with or without reasonable accommodation?	( ) Yes	( ) No

Do you understand that due to the nature of the services we provide, an exceptional record of attendance, promptness, and dependability is required of all Hospital employees? ( ) Yes ( ) No

Do you understand that employment is contingent upon passing a health screening, satisfactory education, prior employment, and reference verifications? ( ) Yes ( ) No

Do you understand that the first few months of employment at CRH will be considered an initial employment period and/or adaptation and that employment may be terminated during this period by either the employee and/or employer without prejudice and with no eligibility for accrued or severance pay?

( ) Yes ( ) No

I agree to employment health screening at CRH and in the event of a working injury, the hospital has my consent for treatment in the Emergency Department. In the event I am photographed during the course of my employment, the hospital has my permission to use any and all photos for various hospital community relations purposes. I understand that this employment application or the granting of an oral interview does not constitute a contract of employment or a promise of future benefits by Calais Regional Hospital. I also understand and agree that if hired, my employment will be for no specific duration, will be at-will in nature and may be terminated, with or without cause, at any time by either myself or my employer. In the event of my employment with the Hospital, I agree to abide by all established rules and procedures, however, I understand that such rules and procedures will be changed and updated on a regular basis. I hereby acknowledge that I have read, understand and consent to the above statements. I also certify that this written statement supersedes any and all oral representations made by agents or representatives of Calais Regional Hospital.

Background Check Authorization and Releases: I give my express authorization for Calais Regional Hospital and/or its agent(s) to contact my references and otherwise conduct an investigation into my background. I also request and authorize each person to whom this form is presented, to provide Calais Regional Hospital and/or its agent(s) with any information about me that may be requested including, without limitation, information related to my character, job performance and work habits. I understand that this background screening may include inquiries into the following areas: motor vehicle and criminal records, verification of education and licenses, employment verification, and verification of submitted application information.

Release and Holds Harmless: I agree to release and hold harmless Calais Regional Hospital and/or its agent(s) and any person or organization providing information to them from any claims I may have, now or in the future, relating in any manner to giving or receiving this information, including without limitation, claims for slander, defamation and wrongful termination.

Acknowledgement of Understanding: I understand that Calais Regional Hospital and/or its agent(s) may conduct an investigation into my background and that by signing this form I am releasing Calais Regional Hospital, its agents and those contacted by Calais Regional Hospital and/or its agents from any liability associated with such investigation. I also understand that I may be refused employment on the basis of the information received as the result of an investigation into my background and/or that my employment may be discontinued on the basis of information received as the result of any investigation into my background.

_____________________________________	________________________________________________________________________
Date	Signature of Applicant

The Federal Age Discrimination in Employment Act of 1987 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age. The State of Maine prohibits the use of a mandatory retirement age. Calais Regional Hospital is an Equal Opportunity Employer as outlined in the Federal Civil Rights Act of 1964 and the State of Maine Human Rights Act as amended. All applicants for employment are treated in a non- discriminatory manner regardless of their race, color, sex, physical or mental handicap, religion, sexual orientation, ancestry, national origin, or age.

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