This application shall become void after 30 days but can be reactivated for an additional 30 days by written request of the applicant. Equal opportunity is given to all applications regardless of race, creed, color, national origin, sex, age or individuals with disabilities.
Account for all employment, including period(s) of unemployment. Start with the most recent.
Shift & Travel Availability
Day (7 to 3)Evening (3 to 11)Night (11 to 7)Extended Day (7 a.m. to 7 p.m.)Extended Night (7 p.m. to 7 a.m.)Full-timePart-timeOther
Day onlySome Often NoneOvernightSome Often None
License & Registration Information for Nurses & Professional Individuals
Specialized Hospital Experience
Physical Therapy Aid
Medical Records Clerk
Specialized Office Experience
Additional Work Experience
Authorization to Release Information
I authorize the hospital/company, or its agent, to obtain any information about my work history or personal information, including my character and qualification, credit rating, driving record, criminal record, education and previous employment. I authorize all persons, schools, companies, information service bureaus, governmental agencies and law enforcement authorities to release any information concerning my background to the hospital/company, whether or not it is in their records. I also authorize the hospital/company to obtain this information from any company that is in the business of providing applicant background checks. I hereby release the individuals or entities providing this information from all liability or any damage caused by issuing this information.
I certify that the answers given by me to the foregoing questions and statements are true and complete to the best of my knowledge, and that I have withheld nothing that would, if disclosed, affect this application unfavorably. I acknowledge that misrepresentation or omission of facts called for in this application is cause for my not being hired or my termination at any time without previous notice to me.
I authorize the hospital/company to release to other prospective employers or information services bureaus any information regarding my employment with the hospital/company or the information set forth in this application or gained by the hospital/company from any other companies, agencies, schools or persons named in this application, including information regarding my employment, character qualifications, and other information they may have regarding me, whether or not it is in their records. I hereby release the hospital/company from all liability for any damage caused by issuing this information to outside individuals.
I agree to submit myself upon request by the hospital/company, subsequent to a conditional job offer, for physical examination by a physician designated by the hospital/company, and to future physical or mental examinations the hospital/company may require at a later date as a condition of continued employment.
If employed, I agree as a condition of continued employment to acquaint myself with , and to abide by all Rules, Regulations and Policies as established or amended by the hospital/company. However, I understand that my employment and compensation can be terminated with or without notice at any time, and for any reason, at the option of the hospital/company or myself. Nothing in this Application of Employment should be construed to constitute a contract of employment between the hospital/company and the applicant. I understand that my terms and conditions of employment may be changed at any time.
If I am employed, I further understand and agree that when my employment is terminated by retirement or otherwise, I must return all of the hospital/company's property in my custody, including, but not limited to, any documents, hospital/company equipment, office keys, manuals, identification cards, and name pins before I am entitled to final payment of any amounts due me on separation. I also understand that the value of these items, if not returned, along with any monies I might owe the hospital/company, may be deducted from my final paycheck.
I Authorize to Release Information.