NSMC-Employee-Application

Date of Application

MonthDayYear
Date
Position(s) applying for
Equal opportunity is given to all applicants regardless of race, color, age, sex, religion, national origin, disability, pregnancy, genetic information, and military or veteran status.

This application shall become void after 30 days but can be reactivated for an additional 30 days by written request of the applicant.
PERSONAL INFORMATION
First
Middle
Last
Address
City
State
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Email
example@example.com
Salary Required
Date available to start work if a position is offered

MonthDayYear
Date
Are you at least 18 years of age?

YesNo
Have you ever applied for work here before?

YesNo
If yes, when?
Have you ever worked here before?

YesNo
If yes, when?
Are you either a U.S. citizen or an alien who has the legal right to work in the U.S.?

YesNo
Have you ever been convicted of a crime or pled guilty or nolo contendere to a charge involving moral turpitude, abuse, assault, battery, arson, larceny, robbery, burglary, sex offences (including gratification of lust), identify theft, possession or sale of drugs, murder, manslaughter, or any other crime involving a vulnerable adult or child?

YesNo
If yes, explain
Are you able to perform the essential functions of the position(s) for which you are applying with or without a reasonable accomodation?

YesNo
Do you have a reliable means of transportation to work?

YesNo
Do you have personal or other obligations that would cause you to miss work?

YesNo
If yes, explain
If hired, will you be engaged in any other work, business, or school?

YesNo
If yes, explain
How did you find out about this position?

Current EmployeeJob PostingNewspaper AdOur WebsiteSocial MediaOther
Name of person that referred you?
Do you have relatives working for our Facility?

YesNo
If yes, provide name(s)
1. If offered a position, the Immigration Reform and Control Act of 1968 requires you to furnish proof of your employment authorization and your identity before you begin work.
2. If offered a position, a background check, including a criminal record check, will be conducted.
Shift & Travel Availability
Schedules can you work? (Check all that apply)

DayEveningNightRotatingWeekendHoliday
Employment Status Desired?

Full TimePart TimePRNTemporary
How often are you willing to Travel?

Day OnlyNoneSomeOften
How often are you willing to travel?

OvernightNoneSomeOften
License and Registration Information for Nurses and Professional Individuals
State 1
License Number 1
Expiration Date 1
Type 1
State 2
License Number 2
Expiration Date 2
Type 2
State 3
License Number 3
Expiration Date 3
Type 3
Have you ever had or do you currently have a restricted license?

YesNo
If yes, explain
Educational Information - Include Military Education and Training
High School - Name and Address of School
High School - Number Years Completed
High School - Graduated (Yes or No)
High School - Degree/Major
College - Name and Address of School
College - Number Years Completed
College - Graduated (Yes or No)
College - Degree/Major
Graduate School - Name and Address of School
Graduate School - Number Years Completed
Graduate School - Graduated (Yes or No)
Graduate School - Degree/Major
Special Training - Name and Address of School
Special Training - Number Years Completed
Special Training - Graduated (Yes or No)
Special Training - Degree/Major
Employment History - Account for all employment, starting with the most recent job. You may attach additional pages if necessary.
Company Name & Address 1
# Years Employed 1
Final Position 1
Supervisor's Name & Contact Number 1
Describe Duties 1
Salary 1
Reason for Leaving 1
Company Name & Address 2
# Years Employed 2
Final Position 2
Supervisor's Name & Contact Number 2
Describe Duties 2
Salary 2
Reason for Leaving 2
Company Name & Address 3
# Years Employed 3
Final Position 3
Supervisor's Name & Contact Number 3
Describe Duties 3
Salary 3
Reason for Leaving 3
Company Name & Address 4
# Years Employed 4
Final Position 4
Supervisor's Name & Contact Number 4
Describe Duties 4
Salary 4
Reason for Leaving 4
Military Service? Branch:
# Years Served:
Rank Achieved
Duties
Were you honorably discharged?
May we contact your current employer?

YesNo
Specialized Healthcare & Office Experience
Number of Years
Check all that apply

Nurse SupervisorRegistered NursePractical NurseNurse AideEKG/EEG TechRespiratory TherapyRadiological TechUnit SecretarySurgery Tech
Number of Years
Check all that apply

SecurityFood ServiceHousekeepingLaundryPhysical TherapyPhysica Therapy AideOccupational TherapyMedical RecordsCoding/Billing
Number of Years
Check all that apply

TransportationLaboratory TechMaintenanceElectrical MaintenanceHeating & AirPharmacy TechPurchasingHuman ResourcesPublic Relations
Number of Years
Check all that apply

Secretarial/ClericalAccountingBookkeepingCashierMS WordMS ExcelMS PowerPointInformation TechnologyOther
Last
First
M.I.
Date:

MonthDayYear
Date
I authorize North Sunflower Medical Center, or its agents, to obtain any information about my work history or personal information, including my character and qualification, credit rating, driving record, criminal record, education and previous employment. I authorize all persons, schools, companies, information service bureaus, governmental agencies and law enforcement authorized to release any information concerning my background to North Sunflower Medical Center, whether or not it is in their records. I also authorize North Sunflower Medical Center to obtain this information from any company that is in the business of providing applicant background checks. I hereby release the individuals or entities providing this information from all liability of any damage caused by issuing this information.
Date

MonthDayYear
Date
Signature of Applicant

Clear
Please provide at least three (3) work references: References could be contacted by personnel of North Sunflower Medical Center (supervisors or administration). These references should be able to provide accounts of your character and/or qualifications to perform the job for which you are applying. Please be assured that all information obtained from these references will be held in strict confidence.
Name of contact:
Title:
Phone Number

Area CodePhone Number
Company:
Address:
Apartment/Unit #:
City:
State:
Zip Code
Name of Contact:
Title:
Phone Number

Area CodePhone Number
Company:
Address:
Apartment/Unit #
City
State
Zip Code:
Name of Contact
Title:
Phone Number

Area CodePhone Number
Company:
Address
Apartment/Unit #
City
State
Zip Code:
READ CAREFULLY

DISCLOSURE AND AUTHORIZATION TO RELEASE CONSUMER INFORMATION

In connection with your employment or application for employment with Healthcare Facility, a consumer report may be obtained. A consumer report includes any written, oral, or other communication of any information by a consumer reporting agency bearing on a consumer's credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. By signing this form below, you hereby authorize Healthcare Facility and any of its agents, to obtain a consumer report on you.

I HEREBY AUTHORIZE HEALTHCARE FACILITY, AND ANY OF ITS AGENTS, TO OBTAIN A CONSUMER REPORT ON ME.
DATE

MonthDayYear
Date
SIGNATURE OF APPLICANT/EMPLOYEE

Clear
READ CAREFULLY

DISCLOSURE AND AUTHORIZATION TO RELEASE CONSUMER INFORMATION

I certify that the answers given by me to the foregoing questions and statements are true and complete to the best of my knowledge, and that I have withheld nothing that would, if disclosed, affect this application unfavorably. I acknowledge that misrepresentation or omission of facts called for in this application is cause for my not being hired or my termination at any time without prior notice to me.

I authorize Healthcare Facility to release to other prospective employers of information service bureaus, any information regarding my employment with healthcare Facility or the information set forth in this application or gained by Healthcare Facility from any other companies, agencies, schools or persons named in this application, including information regarding my employment, character, qualification and other information they may have regarding me, whether or not it is in their records. I hereby release Healthcare Facility from all liability for any damage caused by issuing this information to outside individuals.

If employed, I agree as a condition of continued employment to acquaint myself with, and to abide by all Rules, Regulations and Policies as established or amended by Healthcare Facility. However, I understand that any employment is at-will which means that my employment and compensation can be terminated with or without notice at any time, and for any reason other than an illegal reason, at the option of Healthcare Facility or myself. Nothing in this Application of Employment or the regulations and policies of the Healthcare Facility should be construed to constitute a contract of employment between Healthcare Facility and the applicant. I understand that no Healthcare Facility representative, other than the Administrator, in writing, has any authority to enter into an agreement for employment for any specified period of time, or to make any agreement contrary to this policy. I understand that my terms and conditions of employment may be changed at any time with or without notice to me.

If I am employed, I further understand and agree that when my employment is terminated for any reason, I must return all of the healthcare Facility's property in my custody, including, but not limited to, any documents, Healthcare Facility equipment, office keys, manuals, identification cards and name badges before I am entitled to final payment of any amounts due me on separation. I also understand that the value of these items, if not returned, along with any monies I might owe Health Facility, may be deducted from my final paycheck; to the extent as allowed by law.
DATE

MonthDayYear
Date
SIGNATURE OF APPLICANT

Clear
AUTHORIZATION TO RELEASE EMPLOYMENT AND EDUCATION RECORDS

I, ______________________ hereby authorize Healthcare Facility, or its agents, to obtain all records and/or information relating to my education and employment history. I hereby authorize all persons, entities or agencies possessing records and/or information relating in any way to my education and employment history to release all such information to Healthcare Facility's Human Resources Department.

I hereby release Healthcare Facility, and its agents, from any and all liability related in any way to its request or receipt of the information authorized herein, and I do also hereby release any and all persons, entities or agencies possessing records and/or information relating in any way to my education and employment history for any and all liability related in any way to the release of information in accordance with this Authorization.
I ________________
DATE

MonthDayYear
Date
SIGNATURE OF APPLICANT

Clear
Should be Empty:

PERSONAL INFORMATION

License and Registration Information for Nurses and Professional Individuals

Educational Information - Include Military Education and Training

Employment History - Account for all employment, starting with the most recent job. You may attach additional pages if necessary.

Specialized Healthcare & Office Experience