HH Lincoln Health Employment Application

Date of Application

Date

Full Name*

First NameMiddle NameLast Name

Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address

example@example.com

Phone Number*

What is your shift availability/preference?*

What type of position are you interested in?*

Full-timePart-timePRNTemporary

What position are you applying for?*

Please enter the position title as it appears on the website.

What is your requesting rate or salary?*

Are you at least 18 years of age?

YesNo

Are you legally authorized to work in the US?

YesNo

How did you hear about us?*

If referred by a Lincoln Health employee, please list name of employee that referred you.

Available Start Date

Have you ever been employed by HH Lincoln Health or any Huntsville Hospital affiliate?*

YesNo

If so, please specify name of organization and provide dates of employment.*

Are you related to any current HH Lincoln Health employee(s)?*

YesNo

Are you currently excluded from participation in any federally funded healthcare program - including Medicare and Medicaid - and re you aware of any potential exclusion from a federally funded health program?

YesNo

Are you able to perform the essential job related functions of the position for which you are applying for with or without reasonable accommodations?

YesNo

Have you ever been convicted of a crime?

YesNo

Work History - Job 1*

Work History - Job 2

Work History - Job 3

Education - School 1

Education - School 2

Education - School 3

Professional Licensing, Registration, and Certification 1

Professional Licensing, Registration, and Certification 2

Skills - Please check the boxes that apply to you for any of the below skills/experience you posses.

Electronic Medical Record SoftwareMicrosoft Office (Word, Outlook, Excel, PowerPoint)Other

Reference 1*

Reference 2*

Reference 3*

Disclosure

HH Lincoln Health is an equal opportunity employer. All statements made by applicants for employment on this online application will be checked for accuracy. We offer equal employment opportunities to all persons without discrimination on the basis of race, color, religion, age, sex, pregnancy, gender identity, sexual orientation, national origin, citizenship status, physical or mental disability, genetic information or past, present, or future service in the Uniformed Services of the U.S., or any other legally protected status. The submittal of this online application does not obligate us in any way.

I certify that the information given by me in this application is true in all respects, and I agree that if the information given is found to be false in any way, it shall be considered sufficient cause for denial of employment or discharge. I authorize the use of any information in this application to verify my statements, and I authorize past employers, all references, and any other persons to answer all questions asked concerning my ability, character, reputation, and previous employment record. I release all such persons from any liability or damages on account of having furnished such information. I understand that a consumer credit report may be obtained.

I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between the company and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the company unless made in writing. If an employment relationship is established, I understand that I have the right to terminate my employment at any time and that the company retains the same right.

If I am offered employment, I agree to submit to a physical examination, including a drug screen. Refusal to submit to a drug screen or physical examination, falsification of the drug screen or medical information provide, or a positive finding on the drug screen will preclude Lincoln Health System from further consideration of my application. I understand my becoming employed and/or my continued employment are subject to the results of any physical examination related to my job duties in accordance with company policies and procedures.

I understand that if employed, policies, and rules which are issued are not conditions of employment and that the employer may revise policies or procedures in whole or in part, at any time.

I understand that this application will be kept on active file for 2 years from the date completed, after which time I would have to reapply in accordance with established company procedures.

I understand the above and wish to proceed.*

YesNo

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