Gordon Hospital is an equal opportunity employer. Qualified applicants will be considered for employment without regard to race, color, religion, sex, marital status, age, national origin, ancestry, disability/handicap (physical or mental). Gordon Hospital prohibits any form of harassment in the workplace. Information on this application will not be used to discriminate against any applicant.
If you feel you cannot answer a question for personal reasons, please consult with the employment interviewer at the time of your interview.
Name MI Last Name
Date Email
Mailing Address
Street City State Zip
Telephone () Social Security No.
Residence Other
Have you ever used any name(s) for work, school or other reasons? If yes, list name(s) and dates/locations used and
circumstances.
Person to Notify in Case of Emergency
Name Telephone
Position Desired
Gordon Hospital accepts applications for vacant positions. List in order of preference the positions for which you wish to be considered:
1) 2)
Is there any specialty you desire in the positions for which you are applying?
Date available for employment Salary desired
If not the above, what hours/days can you work?
Work History
Have you ever (Check All That Apply) applied for worked for this facility or another facility
affiliated with Gordon Hospital? Yes No If yes, provide details in Work History below.
Do you have relatives employed by Gordon Hospital? Yes No
If yes, provide name(s), position(s), location and department(s).
This facility is a tobacoo-free work place. Do you use currently tobacoo products? Yes No
Provide complete information on all employment (full-time, part-time and temporary/PRN) for the past 10 years or your 5 most recent employers, whichever is greater. Explain all periods of unemployment.
May we contact your present employer at this time? Yes No (References will be required before employment)
Have you ever been discharged or asked to resign by any employer? Yes No
If yes, provide information on employer, date, action and explanation
Education
Professional References (Co-workers who have known you for at least two years):
Name Telephone
Address
Relationship to Reference listed:
Name Telephone
Address
Relationship to Reference listed:
Name Telephone
Address
Relationship to Reference listed:
Licensure/Certification/Debarment
Do you currently hold all licenses/certifications required by governmental authorities, licensing agencies, or the facility for the position for which you are applying? Yes No
If yes, provide license/registration numbers and issuing states:
Have you ever been denied a professional or occupational license, registration or cerificate? Yes No
Has your license, registration or certificate ever been investigated, revoked, suspended, limited, or subject to
discipline by any board or governing authority? Yes No
Have you ever been debarred,excluded or suspended from participation in any procurement or other program
involving payment or reimbursement for health care or other services sponsored, conducted or funded by
the Federal Goverment?
Yes No
Are you presently subject to any proceeding which might result in such debarment,exclusion or suspension?
Yes No
If you answered yes to any of these questions, please explain in detail:
Skills
Please list all languages (including English) that you speak, read or write proficiently:
Have you had any training or experience in any of the following areas?
Typewriter WPM Microsoft Word Word Perfect CT Scanner
Transcription Machine
Describe other computer software programs, business machines or medical equipment that you operate proficiently:
List any other qualifications you have for the position for which you have applied:
Criminal History Information
There is no time limit to the question regarding your ciminal history. Unless a time limit is stated in a question, you must include information on ALL convictions, please and alternative adjudications that have occurred during your lifetime. Records of offenses by minors (under age 18) are not automatically sealed and should also be disclosed, except where non-disclosure is required under state law.
If you are uncertain of the exact date or how a criminal offens was classified. State the approximate date, you understanding of the criminal classification, and note that you are unsure of any more specific information.
Have you ever (1) been convicted of, (2) plea bargained to , (3) entered a plea of nolo contendere or no contest to, (4) had adjudication withheld for or (5) participated in a pre-trial diversion program for a crime, excluding any misdemeanor traffic offenses? (Answering 'Yes' to this question is not an automatic bar to consideration for employment. The particular circumstances will be considered.)
Yes No
If you answered yes to any of these questions, provide complete information on all criminal offense(s), date(s), location(s), (city/county and state) and disposition:
Have you EVER served any of the following for any criminal offense? (Check all that apply)
NOTE: This list of dispositions is not a complete description of every possible alternative sentencing option. If the alternative disposition you received is not specifically listed below, you MUST disclose it by checking the last option and specifically describing the program. Failure to disclose any type of alternative disposition will be considered falsificationand will result in you ineligibility for employment.
Motor Vehicle Record
The following section should be completed only if you are applying for a position which requires operation of a motor vehicle (owned by the facility or you): Driver's License No.
Type of License: Personal Commercial(CDL) Issuing State: Expiration Date
Is your driver's license limited in any manner? Yes No
If yes, please describe in detail:
Has your driver's license ever been denied, curtailed, suspended or revoked? Yes No
If yes, provide complete information on action(s) taken, dates(s), location(s) and disposition/current status:
Have you had any moving violations during the past 5-years? Yes No
Have you been convicted for any driving offenses during the past 5-years? Yes No
Have you pled guilty to any driving offenses during the past 5-years? Yes No
Have you pled nolo contrendre (no contest) to any driving offenses during the past 5-years? Yes No
If you answered yes to any of the above questions, provide the offense(s), location (city/state), date(s) and
disposition/current status:
Do you have current automobile liability insurance? Yes No
If yes, provide expiration date:
Application Procedure
This facility may not interview all applications for vacancies. Those applicants to be interviewed will be contacted by the facility. Applications will only be accepted for specific job positions and will be considered active for ninety (90) days following their submission. If applicants wish to be further considered after this time period, or for a job position not listed on this application, they must submit a new application.
Application Verification
| 1. | | I verify that all the information on this application and on resumes and exhibits submitted to the facility is true, correct, and complete. I have not omitted any information sought by the facility. I understand that if the facility requests a background check/criminal record check under the Fair Credit Reporting Act, I will receive a separate notice regarding this investigation and must provide written authorization as a condition of consideration for employment. | | 2. | | I understand that this application is not a job offer or a contract of employment for any specific time period. If hired, I understand that any employment will be 'at-will' and for an indefinate time period. I understand that I may resign or be terminated by the facility at any time without notice or requirement of cause. | | 3. | | Employment is subject to completion of pre-employment procedures, including but not limited to, verifying employment/personal references; conducting a background investigation/criminal record check; verifying driving record (if applicable); and confirmation of licensure or registration. | | 4. | | I understand that an offer of employment in certain positions may require a post-offer, pre-hire medical examination or completion of a medical questionnaire. If I decline to submit to the medical examination, or decline to answer medical question, I will not be further considered for employment. | | 5. | | Applicants hired by the facility must complete a Federal I-9 form and provide verifying documentation of their legal right to reside and work in the United States. | | 6. | | All applications extended a conditional job offer will be requested to submit to testing for the current illegal use of drugs and for nicotine .Any applicant who declines to consent or submit to testing, or who tests positivefor the illegal use of drugs and/or nicotine will not be further considered for employment. |
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