test application | Salem Township Hospital

Online Employment Application

Last Name *

First Name *

Middle

Phone *

Street Address *

City *

State *

Zip Code *

Email *

Best Contact Time

Date Available for Work

Previous Name(s)?

Please identify including maiden name.

Position Applied for:

Salary Desired:

Reference

Are you a U. S. Citizen or an alien legally authorized to work in the U. S.? *

Yes

Shift Availability

Days

Evenings

Nights

Have you ever been employed by this facility? *

Yes

Would you consider:

Full Time (72-80 hours every 2 weeks)

Part Time (30-72 hours every 2 weeks)

Less than Part Time (less than 30 hours every 2 weeks)

PRN/Float Pool (used to fill in as needed)

Are you 18 years of age or older? *

Yes

Relatives/Friends Employed?

List Name, Department, Relationship

Long Range Occupational Goals:

High School Name and Address *

Diploma/GED

Did you graduate High School? *

Yes

College/University Name & Address

College Degree(s)

Did you graduate from College?

Yes

Areas of Specialization or Major Interest:

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

List Office Skills including Computer/Software Experience (Include Word Processing, approximate WPM):

List Health Care, Business or Industrial Equipment Operated:

Professional License (List Type, State, No., and Date):

License Status

Currently Licensed

Currently Registered

Eligible for License

Eligible for Registration

License or Registration Ever Suspended, Revoked or on Probation?

Yes

Please explain any Suspension, Revokation or Probation:

Additional Professional License (List Type, State, No., and Date):

Additional License Status

Currently Licensed

Currently Registered

Eligible for License

Eligible for Registration

License or Registration Ever Suspended, Revoked or on Probation?

Yes

Please explain any Suspension, Revokation or Probation:

Professional Certification (List Type, State, and Date):

Certification Status

Currently Certified

Eligible for Certification

Additional Certification (List Type, State, and Date):

Additional Certification Status

Currently Certified

Eligible for Certification

Briefly describe Duties and Skills acquired through Military or Volunteer Service: (Include Dates)

Job Title

From: (Mo/Yr)

To: (Mo/Yr)

Salary (hr/mo/yr)

Employer Name

Employer Address

Employer Phone

Supervisor Name

May We Contact?

Yes

Duties

Reason for Leaving

Job Title

From: (Mo/Yr)

To: (Mo/Yr)

Salary (hr/mo/yr)

Employer Name

Employer Address

Employer Phone

Supervisor Name

May We Contact?

Yes

Duties

Reason for Leaving

Job Title

From: (Mo/Yr)

To: (Mo/Yr)

Salary (hr/mo/yr)

Employer Name

Employer Address

Employer Phone

Supervisor Name

May We Contact?

Yes

Duties

Reason for Leaving

Job Title

From: (Mo/Yr)

To: (Mo/Yr)

Salary (hr/mo/yr)

Employer Name

Employer Address

Employer Phone

Supervisor Name

May We Contact?

Yes

Duties

Reason for Leaving

Reference Name *

Non-Relatives Only

Company Name and Title/Position *

Company Phone Number & Address *

Reference Name

Non-Relatives Only

Company Name and Title/Position

Company Phone Number & Address

Reference Name

Non-Relatives Only

Company Name and Title/Position

Company Phone Number & Address

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

Yes

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

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

If Yes, explain:

Date and Name (E-Signature) *

Carefully read this section prior to providing signature. 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 written agreement signed by an administrative representative of this facility and notarized.