Baptist Health System Employment Application

Application for Employment
Confidential

Federal and state laws prohibit descrimination in employment because of sex, age, race, color, religious creeds, sexual preference, marital status, national origin, ancestry, citizenship, liability for service in the armed forces of the United states or disability. All applications will be kept on file for one year.

Personal Information

Date of Application

MonthDayYear

Date Available

MonthDayYear

Name (Last, First, Middle)

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

E-mail

Permanent Address (if different from mailing address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

If you cannot be reached at the above numbers, where may we contact you?

Name of person

Phone Number

Area CodePhone Number

If hired, can you provide proof that you are eligible to work in the United States?

Employment Desired

Position applying for:

First Choice

Shift

Salary

Second Choice

Shift

Salary

Third Choice

Shift

Salary

Will you accept employment of:

Full time?Part time?

Are you currently employed?

May we contact your employer?

If no, why?

If under 18, do you have a NY State Student Employment Certificate?

How did you hear of this opening?

Education

Highest grade completed?

Scholastic honors received?

Grammar or grade school

Name of Grade School

Location (city, state)

Date Completed

High School

Name of High School

Location (city, state)

Date Completed

Type of degree earned

College

Name of College

Location (city, state)

Date Completed

Type of degree earned

Vocational or Business School

Name of Vocational/Business School

Location (city, state)

Date completed

Type of degree earned

Professional Education

Name of Professional School

Location (city, state)

Date completed

Type of degree earned

Extracurricular activities or other qualifications that you feel are related to the position for which you are applying:

Have you ever been in the US Armed Forces?

Type of training obtained pertinent to position?

Professional Licenses and/or Certifications

Documents verified on:

Type of certificate:

Issued by:

Date issued:

Number:

Are you related to anyone in our employment? Who and how?

Have you filed an application before?

YesNo

If yes, when?

Have you been employed here before?

YesNo

Employment Record
(list last or present position first)

Employer #1

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Job Title

Supervisor

Dates employed (from - to)

Hourly salary/rate (start - final)

Duties performed:

Reason for leaving:

Employer #2

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Job Title

Supervisor

Dates employed (from - to)

Hourly Rate/Salary (start - end)

Duties performed:

Reason for leaving:

Employer #3

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Job Title

Supervisor

Dates Employed (from - to)

Hourly Rate/Salary (start - final)

Duties performed:

Reason for leaving;

Employer #4

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Job Title

Supervisor

Dates Employed (from - to)

Hourly Rate/Salary (start - finish)

Duties performed:

Reason for leaving:

Personal References

If you need to attach an additional document for references or work history, please upload here or email to pieniazeky@bapthealth.com.

Upload file:

Upload a File

Reference Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Business

Reference Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Business

Reference Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Business

Please explain all periods of unemployment:

If your references, education, or military service records are under a name other than indicated on the front of application, please indicate (last name, first name, middle initial.)

Have you ever been convicted of a crime?

What type?

(Convictions will not automatically disqualify an applicant for a particular job. All aspects of an applicant's history will be considered.)

Are you able to perform the essential duties of the jobs for which you have applied, with or without accommodation?

YesNo

If no, please describe any tasks which you are NOT able to perform with or without an accommodation:

Employment Disclaimer

I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies, or corporations supplying such information. I also understand that there will be a criminal background check as part of the hiring procedure.

After a tentative offer of emplyment has been made, I agree to take a medical examination at no personal expense and authorize the examining physician to discluse the findings to the Company.

I understand that I will be required to follow the personnel policies and rules of the Baptist Health System and that infractions of said rules may lead to dismissal. I also understand that my employment may be terminated for any missttement or omission of fact appearing on the application form, or physical examination form.

I understand tht this institution follows the "fair employment practice code" and the "fair housing code" and that there is no discrimination in the hiring of individuals or the housing of individuals.

I understand that this application is not intended as a contract of employment. I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time, with or without notice, for any reason.

Your name

Date