Application For Employment

Application For Employment

Monroe County Hospital provides equal opportunities without regards to race, color, religion, sex, national origin, disability or age. MCH complies with the Americans with Disabilities Act of 1990 and the ADA Amendment of 2008. Selected candidates will be required to undergo alcohol/drug screening and a background check.
Position Applied For *.
Type of position applied for:*
Department:*
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Have you been convicted of a criminal offense other than traffic violation?*

YesNo
If yes, give dates and details below. Nature of crime will be considered in relation to position for which you are applying:
Date you can begin work:*

MonthDayYear
Select times you can work:*

DayEveningNightWeekend
Will you accept part-time work?*

YesNo
Will you accept temporary work?*

YesNo
Will you work overtime when scheduled or requested?*

YesNo
List your special skills or training and computer skills:*
Education
Name of School
Location
Dates Attended   Date   Date
Graduate?   Yes   No
Degree or Major Studies
Name of School
Location
Dates Attended   Date   Date
Graduate?   Yes   No
Degree of Major Studies
Professional License or Certification
Type
State
Date Issued    Date
Expiration Date   Date
License Number
Type
State
Date Issued   Date
Expiration Date   Date
License Number
Employment History

List current and previous employers below. Explain any lapses between times when employed in comment section.
Employer   Employer*
Address   Street Address*   Address Line 2*   City*   State*   Zip*
Dates (Begin/End)   Date*   Date*
Position   Position*
Reason Left   Reason Left*
Employer   Type a label
Address   Street Address   Address Line 2   City   State   Zip
Dates (Begin/End)   Date      Date
Position
Reason Left   Type a label
Employer   Type a label
Address   Street Address   Address Line 2   City   State   Zip
Dates (Begin/End)   Date      Date
Position
Reason Left   Type a label
Comments:
Have you ever been discharged from a job or forced or asked to resign?*

YesNo
Have you ever been excluded or sanctioned for fraudulent practices with Medicare/Medicaid?*

YesNo
Can you perform the position for which you have applied with or without accommodations?*

YesNo
Were you referred by a Monroe County Hospital Employee?*

YesNo
If yes, please list the employee's first and last name: First Name Last Name
I HEREBY AUTHORIZE MY CURRENT AND/OR FORMER EMPLOYERS TO RELEASE INFORMATION PERTAINING TO MY CURRENT WORK RECORD, MY WORK HABITS, AND MY WORK PERFORMANCE WHILE IN THEIR EMPLOY. IF YOU DO NOT WANT US TO CONTACT YOUR CURRENT EMPLOYER, PLEASE NOTE __________________________________________________________________

I HEREBY STATE THAT THE INFORMATION GIVEN BY ME IN THIS APPLICATION IS TRUE IN ALL RESPECTS. I AGREE THAT IF I AM A SELECTED CANDIDATE, OR AN EMPLOYEE OF MONROE COUNTY HOSPITAL, AND THE INFORMATION IS FOUND TO BE FALSE IN ANY RESPECT, THE HOSPITAL WILL WITHDRAW ITS CONDITIONAL OFFER OF EMPLOYMENT OR DISMISS ME AT ANY TIME.

I UNDERSTAND IF I AM EMPLOYED (OR AFFILIATED AS A TRAINEE) WITH THIS FACILITY THAT I AM REQUIRED TO: 1) FOLLOW OUR ORGANIZATION’S POLICIES AND PROCEDURES, 2) COMPLY WITH RULES AND REGULATIONS OF ALL FEDERAL, STATE, AND LOCAL GOVERNMENTS, 3) DETECT AND REPORT ILLEGAL OR UNETHICAL ACTIONS TO MY SUPERVISOR OR THE COMPLIANCE OFFICER OR THE HEALTHCARE ETHICS LINE (HOTLINE PHONE NUMBERS ARE POSTED ON EMPLOYEE BULLETIN BOARDS).
Resume (Optional)

Cancelof
Signature*
Today's Date*

MonthDayYear
Date
Should be Empty:

Application For Employment

Education

Professional License or Certification

Employment History