Application for Employment

Application for Employment

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McKenzie Health System offers equal employment opportunity to all qualified persons, without regard to race, religion, color, national origin, age, sex, height, weight, familial status, marital status, disability, or any other characteristic protected by law. Assistance will be provided to you in completing this application and/or job interview upon request.
Position applying for
Personal Information
Today's Date*

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
Other name(s) if any, under which you have worked or attended school
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Please enter a valid phone number.
Are you 18 years or older*

YesNo
Email*
example@example.com
How did you learn about us?
Do you have any past or currently pending felony charges, in either federal or state court against you?*

YesNo
If yes, please explain:
Are you legally eligible for work in the United States?*

YesNo
If you are not a U.S. Citizen, please list the type of VISA you possess and the expiration date:
Have you ever been temporarily or permanently ineligible or excluded from participation in Medicare, Medicaid, or any other federal or state healthcare program?*

YesNo
If yes, please explain the cause or reason for exclusion or ineligibility, the date of exclusion, the jurisdiction, any penalty, and any other relevant information:
To your knowledge, have any of your prior employers been temporarily or permanently ineligible or excluded from participation in Medicare, Medicaid, or any other federal or state healthcare program?*

YesNo
If yes, to the best of your ability, please indicate which employer, the dates of exclusion, and any other relevant information:
Employment Desired
Date

MonthDayYear
Date
Type of employment desired*
If summer only, specify dates available
Shift Preference
Are you employed now?*

YesNo
If so, may we inquire of your present employer?

YesNo
Can you travel if a job requires it?*

YesNo
Have you ever applied at McKenzie Health System before?*

YesNo
If yes, when?
Have you ever been employed by McKenzie Health System before?*

YesNo
If yes, when?
Education
Name of High School*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
# of Years Completed*
Did you Graduate?*

YesNo
Name of College
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
# of Years Completed
Did you Graduate

YesNo
Course of study
List degree completed
Name of College
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
# of Years Completed
Did you Graduate

YesNo
Course of study
List degree completed
Name of College
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
# of Years Completed
Did you Graduate

YesNo
Course of study
List degree completed
Trade, Business or Correspondence School
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Course of study
# of Years completed
Did you Graduate

YesNo
List degree completed
If you are registered or certified in a profession or trade, please indicate the following:
Profession or Trade:
License or registry number :
State:
Expiration date:
Military
Subject of special study or research work:
U.S. Military Service
Dates rank:
Present member of National Guard or Reserves?

YesNo
Employment History

(List all previous employers, starting with the most recent place of employment)
Name of Employer*
List "N/A" if not applicable.
Date (month and year)
from - to
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Hourly rate/salary
Position/Duties
Reason for leaving
Phone Number
Please enter a valid phone number.
Name of Employer 2
Date (month and year)
(from - to)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Hourly rate/salary
Position/Duties
Reason for leaving
Phone
Please enter a valid phone number.
Name of Employer 3
Date (month and year)
(from - to)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Hourly rate/salary
Position/Duties
Reason for leaving
Phone
Please enter a valid phone number.
Name of Employer 4
Date (month and year)
(from - to)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Hourly rate/salary
Position/Duties
Reason for leaving
Phone
Please enter a valid phone number.
Name of Employer 5
Date (month and year)
(from - to)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Hourly rate/salary
Position/Duties
Reason for leaving
Phone
Please enter a valid phone number.
Name of Employer 6
Date (month and year)
(from - to)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Hourly rate/salary
Position/Duties
Reason for leaving
Phone
Please enter a valid phone number.
References

Give the name of three persons you have worked under the direction or supervision of or 3 persons not related to you, whom you have know at least 3 years.
Name of Reference #1*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Business
Years known
Name of Reference #2*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Business
Years known
Name of Reference #3*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Business
Years known
Physical Record
Do you have any physical limitations that preclude you from performing any work for which you are being considered/applying for? (Do not answer this question unless you have been informed about the requirements of the job for which you are applying.)

YesNo
If yes, what can be done to accommodate your limitation?
In case of an emergency notify:
Name

First NameLast Name
Relationship
Phone
Please enter a valid phone number.
I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND I UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR IMMEDIATE DISMISSAL.

I AUTHORIZE MCKENZIE HEALTH SYSTEM AND ITS AGENTS TO INVESTIGATE ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES LISTED ABOVE, INCLUDING RECORDS OF ANY FORMER EMPLOYERS, EDUCATIONAL INSTITUTIONS, POLICE DEPARTMENTS, CREDIT OR CONSUMER REPORTS, AND ANY OTHER REFERENCES OR SOURCES RELATED TO THIS APPLICATION.

I AUTHORIZE ALL SUCH REFERENCES AND SOURCES TO RELEASE THIS INFORMATION WITHOUT LIABILITY FOR DAMAGE INCURRED IN PROVIDING IT, FURTHER, I RELEASE MCKENZIE HEALTH SYSTEM AND ITS AGENTS FROM LIABILITY AND DAMAGES RELATED TO OR ARISING OUT OF ANY REASONABLE BACKGROUND INVESTIGATIONS.

I UNDERSTAND THAT AN OFFER OF EMPLOYMENT WILL BE CONTINGENT UPON MY ABILITY TO DEMONSTRATE MY LEGAL RIGHT TO REMAIN AND WORK IN THE UNITED STATES.

I UNDERSTAND THIS APPLICATION IS CURRENT FOR ONLY 60 DAYS. AT THE CONCLUSION OF THIS TIME, IF I HAVE NOT HEARD FROM THE EMPLOYER AND STILL WISH TO BE CONSIDERED FOR EMPLOYMENT, IT WILL BE NECESSARY TO FILL OUT A NEW APPLICATION.
Date

MonthDayYear
Date
Name (Signature)*

First NameLast Name
MHS PERSONNEL ONLY

INTERVIEWED BY:
DATE:
COMMENTS:


START DATE:
DEPARTMENT:
JOB CLASSIFICATION:
PAY GRADE LEVEL:
STARTING WAGE:
 EXEMPT  NON‐EXEMPT
 REPLACEMENT    TEMPORARY    SUMMER ONLY    DEPARTMENT TRANSFER
HOURS PER WEEK:
SHIFT HOURS:
APPROVED FOR EMPLOYMENT (DEPARTMENT DIRECTOR/MANAGER SIGNATURE):
DATE:
FINAL APPROVAL FOR EMPLOYMENT (HR ADMINISTRATOR OR DESIGNEE SIGNATURE):
DATE:
Should be Empty:

Application for Employment

Personal Information

Employment Desired

Education

Military

Employment History

References

Physical Record

In case of an emergency notify: