Faith Community Health System

Faith Community Health System

Application for Employment
EQUAL OPPORTUNITY EMPLOYER It is our policy to provide equal employment opportunities(EEO) to all applicants for employment without regard to race, color, religion, gender, sexual orientation, gender identity, national origin, age, disability, genetic information, marital status, amnesty or status as a covered veteran in accordance with applicable federal, state, and local laws, except where a reasonable bona fide occupational qualification exists.
Personal Information
Full Name

First NameLast Name
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

City, State, Zip CodeState / Province

Postal / Zip Code
Position for which you are applying
Check the following options you would consider

Full TimePart TimeTemporary
Do you have any commitments to another employer that might affect your employment with us?

YesNo
If yes, what are the commitments?
Were you previously employed at Faith Community Health System?

YesNo
If so, what position and dates held:
What are your minimum salary requirements?
Date available for work

MonthDayYear
Date
Are you 18 years or older?

YesNo
If under 18, state age
Education and Training

Rows	School Name	City and State	# of Years Attended	Degree Received
Grammar School
High School
College
Trade School

List any other education, training, special skills or certifications/licenses that you possess related to the job.
Professional License/Certification#
Professional License/Certification Type
Issuing Agency
State Agency
Expiration Date
Professional License/Certification#
Professional License/Certification Type
Issuing Agency
State Agency
Expiration Date
List any machines, equipment or software programs on which you are qualified and experienced in operating:
List any languages that you speak fluently:
Military Experience

YesNo
If Yes, what branch?
Rank at Separation
Employment History
Name of Employer
Type of Business
Address

Street Address

Street Address Line 2

City, State, Zip CodeState / Province

Postal / Zip Code
Dates employed from (month/year) to (month/year)
Name & Title of Supervisor
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
May we contact

YesNo
Type of Employment

Full-TimePart-Time
Brief description of duties:
Reason for Leaving
Name of Employer
Type of Business
Address

Street Address

Street Address Line 2

City, State, Zip CodeState / Province

Postal / Zip Code
Dates employed from (month/year) to (month/year)
Name & Title of Supervisor
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
May we contact

YesNo
Type of Employment

Full-TimePart-Time
Brief description of duties:
Reason for Leaving
Name of Employer
Type of Business
Address

Street Address

Street Address Line 2

City, State, Zip CodeState / Province

Postal / Zip Code
Dates employed from (month/year) to (month/year)
Name & Title of Supervisor
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
May we contact

YesNo
Type of Employment

Full-TimePart-Time
Brief description of duties:
Reason for Leaving
Name of Employer
Type of Business
Address

Street Address

Street Address Line 2

City, State, Zip CodeState / Province

Postal / Zip Code
Dates employed from (month/year) to (month/year)
Name & Title of Supervisor
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
May we contact

YesNo
Type of Employment

Full-TimePart-Time
Brief description of duties:
Reason for Leaving
Business References
Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Occupation/Association
Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Occupation/Association
Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Occupation/Association
Additional Information

Please provide any other information you think would be helpful to us in considering you for employment such as additional work experience, activities, certificates, honors received etc. (You may omit all information that would indicate age, sex, sexual orientation, race, religion, color, natural origin or disability.)
CRIMINAL RECORD INFORMATION
During the past ten years, have you ever been convicted of, plead guilty to, or received probation, deferred adjudication, or any other type of alternative method of supervision or correction for a misdemeanor, having a penalty or imprisonment or a fine of more than $500.00 or a felony? (Answering yes is not an automatic bar to employment but will be considered in relation to specific job requirements.)

YesNo
If yes, explain:
Have you been convicted of a crime (exclude minor traffic cases; include DUIs)?

YesNo
Are criminal charges now pending against you?Have you been convicted of a crime (exclude minor traffic cases; include DUIs)?

YesNo
If yes, explain:
AGREEMENT

(Please read the following statement carefully)I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered my application may be rejected and, if employed, my employment may be terminated at any time.

In consideration of my employment, I agree to conform to the company’s rules and regulations, and I agree that my employment and compensation can be terminated with or without cause, and with or without notice, at any time, at either my or the company’s option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause and with or without notice, at any time by the company. I understand that no company representative, other than its president, and then only in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing.
Signature
Print Name
Date

MonthDayYear
Date
Should be Empty:

Faith Community Health System

Personal Information

Education and Training

Employment History

Business References

CRIMINAL RECORD INFORMATION