| POSITION APPLIED FOR:* |
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| PHONE NO.:* |
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| E-MAIL ADDRESS:* |
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| NAME:* |
(Last) (First) (Middle) |
| ADDRESS:* |
(Street) (PO Box) |
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(City) (State) (Zip) |
| Do you have adequate transportation to fulfill your duties at Polk Medical Center?* |
Yes No |
| Do you have any employment, work, or education records under a name other than that listed for employment above? * |
Yes No |
| If yes, please list additional names: |
| CITIZENSHIP |
| Are you either a U.S. Citizen or an alien who has the legal right to work in the job for which you are applying?* |
Yes No |
| CRIMINAL OFFENSES |
| Have you ever been convicted of any criminal offenses other than traffic violations within the past seven years? |
Yes No |
| Have you been released from confinement following a conviction for any criminal offense within the past seven years? |
Yes No |
If yes, give the dates and details of each conviction
(nature of crime will be considered in relation to position for which you are applying):
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| WORK AVAILABILITY |
| Date you can begin work: |
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Shifts you can work:
7am - 3pm 3pm - 11pm 11pm - 7am
7pm - 7am 7am-7pm |
| Will you be available for overtime work? |
Yes No |
| Will you be available for weekend work? |
Yes No |
| Would part-time work be acceptable? |
Yes No |
| Would temporary work be acceptable? |
Yes No |
| Have you ever been employed by HCA, Redmond Regional or Polk Medical Centers? |
Yes No |
If yes, give positions and dates of employment:
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SPECIAL SKILLS OR ABILITIES YOU POSSESS:
(Include any special skills from military service) |
| CPR Typing (at WPM) PC Shorthand (at WPM) |
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Other job related equipment you can operate:
Proficient in Software: |
| Foreign or Sign Language: |
| EDUCATION |
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| EMPLOYMENT LICENSES, REGISTRATIONS, OR CERTIFICATIONS |
| Licenses, etc. |
State |
Number |
Date Issued |
Expiration Date | |
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| EMPLOYMENT HISTORY |
| CURRENT OR MOST RECENT |
From
to |
Company:
|
Phone No.:
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Salary:
|
Address:
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May we contact them?
Yes No |
Job Title:
|
Name While Employed: |
Brief description of duties:
|
| Reason for Leaving: |
Other reference with this employer: |
Immediate Supervisor: |
| 1st PREVIOUS |
From
to |
Company: |
Phone No.:
|
Salary:
|
Address: |
May we contact them?
Yes No |
| Job Title: |
Name While Employed: |
Brief description of duties:
|
Reason for Leaving: |
Other reference with employer:
|
Immediate Supervisor: |
| 2nd PREVIOUS |
From
to |
Company: |
Phone No.:
|
Salary:
|
Address: |
May we contact them?
Yes No |
Job Title:
|
Name While Employed: |
Brief description of duties: |
| Reason for Leaving: |
Other reference with employer: |
Immediate Supervisor: |
| 3rd PREVIOUS |
From
to |
Company: |
Phone No.: |
Salary:
|
Address: |
May we contact them?
Yes No |
| Job Title: |
Name While Employed: |
Brief description of duties: |
| Reason for Leaving: |
Other reference with employer: |
Immediate Supervisor: |
Comments regarding lapses, if applicable:
|
| Have you ever been discharged from a job or forced or asked to resign? |
Yes No |
| Please explain: |
Make any comments you feel we should know concerning your past work or personal history.
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I hereby state that the information given by me in this application is true in all respects. I understand that if I am employed and the information is found to be false in any respect, I will be subject to dismissal without notice at any time. I hereby authorize my former employers to release information pertaining to my work record, my work habits, and my work performance while in their employ. |
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In making application for employment, I understand that an investigative report may be made by a consumer reporting agency or Private Investigator to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable. If such an investigative report is made, I understand that I will receive notice that such a report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.
I understand and agree that any employee handbook which I may receive will not constitute an employment contract, but will be merely a gratuitous statement of Polk Medical Center's current policies. I understand Polk Medical Center reserves the right to require its employees to submit to blood test or urinalysis for alcohol or drug screens, or to allow inspection of bags (including purses or briefcases) or parcels brought into or taken out of Polk Medical Center. I understand that refusal to submit to a urinalysis, blood test or search, when requested to do so, may result in termination of my employment.
I UNDERSTAND AND AGREE THAT IF I AM OFFERED EMPLOYMENT BY POLK MEDICAL CENTER MY EMPLOYMENT WILL BE FOR NO DEFINITE TERM AND THAT EITHER I, OR POLK MEDICAL CENTER WILL HAVE THE RIGHT TO TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE. I ALSO UNDERSTAND THAT THIS STATUS CAN ONLY BE ALTERED BY A WRITTEN CONTRACT OF EMPLOYMENT WHICH IS SPECIFIC AS TO ALL MATERIAL TERMS AND IS SIGNED BY ME AND THE ADMINISTRATOR OF POLK MEDICAL CENTER. |
PERSONAL REFERENCES
(Not to be relatives or previous employers.)
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