Employment Application

Salem Township Hospital is an equal opportunity provider and employer. Applicants for employment are recruited and hired on the basis of merit, qualifications, previous experience, and ability to perform the available work. The Hospital does not discriminate against any qualified applicant on the basis of race, color, religion, spiritual beliefs, sexual orientation, national origin, age, gender, disability, or other characteristics protected by federal, state or local law unrelated to job requirements. 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.

Please complete all sections of the application. *Indicates Required Fields.

Personal Information

First Name *

Middle

Last Name *

Previous Name(s)?

Include maiden name

Phone *

Email *

Address *

Address

City

State/Province

Zip/Postal

Best Contact Time(s)

Preferred Contact Method

Phone

Date Available for Work *

Education

High School Name and Location *

Diploma/GED

Did you graduate High School? *

Yes

College/University Name & Location

College Degree(s)

Did you graduate from College?

Yes

Areas of Specialization or Major Interest:

List Health Care, Business or Industrial Equipment Operated:

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

Licensing & Certification

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:

Add License/Certification Remove License/Certification

Professional Experience

Job Title *

From: (Mo/Yr) *

To: (Mo/Yr) *

Employer Name & Address *

Employer Name & Address

City

State/Province

Zip/Postal

Employer Phone *

Supervisor Name *

May We Contact? *

Yes

Duties *

Reason for Leaving *

Add Employer Remove Employer

References

Professional/Work/School references (Not relatives or personal acquaintances)

Reference Name *

Phone *

Title/Position *

Company Name & Location *

Reference Name *

Phone *

Title/Position *

Company Name & Location *

Reference Name *

Phone *

Title/Position *

Company Name & Location *

Additional Background Information

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:

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

Acknowledgement & 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.

Date

Full Name (E-Signature) *

If you are human, leave this field blank.

Personal Information

Position & Availability

Education

Licensing & Certification

Professional Experience

References

Additional Background Information

Acknowledgement & E-Signature