Apply Online : Application for Employment Personal Full Name (First, Middle, Last) Present Address (Street, City, State, ZIP) # Years lived at this address Former Address (Street, City, State, ZIP) # Years lived at this address Day Phone Evening Phone Cellular Phone Email Address Availability Date Available to begin employment Professional Current License (Type): State: Year: Number: Areas of experience in profession: Type of employment interested in Full Time Part Time Temporary Day Evening Night Weekend Rotating Interests Position title Salary desired Position title Salary desired Educational Data High School Name of School: Did You Graduate?: Address: Type of Degree: Field of Study: Business School, Vocational, or Correspondence School Name of School: Did You Graduate?: Address: Type of Degree: Field of Study: College or University Name of School: Did You Graduate?: Address: Type of Degree: Field of Study: Professional License or Certification Current License (Type): State: Date Issued: Number: Are you at least 16 years of age? Yes No Have you ever been convicted of a crime (excluding parking and petty misdemeanor traffic tickets)? Conviction doesn't necessarily bar your from employment. Yes No If Yes, please explain in full Are you prevented from being lawfully employed in the United States Yes No For reference purposes, have you worked or attended school under a former name? Yes No If yes, please list former name: Have you ever applied here before? Yes No If yes, when? Have you ever been employed by St. Michael's? Yes No If yes, where (dept.) and when? Are any relatives currently employed here? Yes No If yes, give full name: Are you able to perform the essential functions of the job you are applying for? Yes No If no, what accommodation would assist you? How did you hear about St. Michael's? Internet Newspaper Employee Referral Other For Positions Required Driving a Motor Vehicle Only Do you have a valid driver's license? Yes No Driver's License Number Driver's License State of Issue Driver's License Expiration Date Have you had any accidents during the past three years? Yes No If Yes, how many? Have you had any moving violations during the past three years? Yes No If Yes, how many? Office Skills Summary (if applicable to the job you are applying for) Typing Yes No Words Per Minute (WPM) 10-Key Yes No Medical Terminology Yes No Computer experience? Yes No List computer hardware/software with which you are proficient Please list two references other than relatives or previous employers. Name: Occupation: Address: Telephone: Name: Occupation: Address: Telephone: An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying. Work Experience Present or Last Employer Name: Address: Phone: Supervisor: Your Title: Duties: Last Salary: Reason for Leaving: Date Left (Month / Year) Date Began (Month / Year) May We Contact?: Previous Employer 1 Name: Address: Phone: Supervisor: Your Title: Duties: Last Salary: Reason for Leaving: Date Left (Month / Year) Date Began (Month / Year) May We Contact?: Previous Employer 2 Name: Address: Phone: Supervisor: Your Title: Duties: Last Salary: Reason for Leaving: Date Left (Month / Year) Date Began (Month / Year) May We Contact?: Resume (Word or PDF files only!): PLEASE READ CAREFULLY APPLICATION FORM WAIVER In exchange for the consideration of my job application by St. Michael's Hospital & Nursing Home (hereinafter called “the Company”), I agree that: Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of St. Michael's Hospital & Nursing Home, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the Administrator of the Company. Both the undersigned and the Company may end the employment relationship at any time, without specified notice or reason. If employed, I understand that all conditions of employment, including but not limited to, hours, shift, benefits, policies, and salary are subject to change by the Company at any time without prior notice to employees, subject to its obligations under the terms of any currently effective collective bargaining agreement. If employed, I will be required to provide original document which verify my identity and right to work in the United States under the Immigration Reform and Control Act (IRCA) or 1986. the document(s) provided will be used for completing of Form I-9. I authorize investigation of all statements contained in this application. I affirm that all information contained in this application is true and complete and that any misrepresentation, falsification, or willful omission herein shall be sufficient reason for dismissal without any previous notice and/or refusal of employment. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract. I also understand that (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations. I understand that, in connection with the routine processing of your employment application, the Company may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, the Company, will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act. I further understand that my employment with the Company shall be introductory for a period of sixty (60) days, and further that at any time during the introductory period or thereafter, my employment relation with the Company is terminable at will for any reason by either party. BY SUBMITTING THIS FORM YOU ARE AGREEING TO THE TERMS STATED ABOVE. This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications. Thank you for completing this application form and for your interest in St. Michael's
Personal
Professional
Interests
Educational Data
Professional License or Certification
For reference purposes, have you worked or attended school under a former name? Yes No
If yes, please list former name:
Have you ever applied here before? Yes No If yes, when?
Have you ever been employed by St. Michael's? Yes No If yes, where (dept.) and when?
Are any relatives currently employed here? Yes No If yes, give full name:
Are you able to perform the essential functions of the job you are applying for? Yes No
If no, what accommodation would assist you?
How did you hear about St. Michael's? Internet Newspaper Employee Referral Other
For Positions Required Driving a Motor Vehicle Only
Office Skills Summary (if applicable to the job you are applying for)
Please list two references other than relatives or previous employers.
Work Experience
Resume (Word or PDF files only!):
PLEASE READ CAREFULLY APPLICATION FORM WAIVER In exchange for the consideration of my job application by St. Michael's Hospital & Nursing Home (hereinafter called “the Company”), I agree that: Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of St. Michael's Hospital & Nursing Home, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the Administrator of the Company. Both the undersigned and the Company may end the employment relationship at any time, without specified notice or reason.
If employed, I understand that all conditions of employment, including but not limited to, hours, shift, benefits, policies, and salary are subject to change by the Company at any time without prior notice to employees, subject to its obligations under the terms of any currently effective collective bargaining agreement. If employed, I will be required to provide original document which verify my identity and right to work in the United States under the Immigration Reform and Control Act (IRCA) or 1986. the document(s) provided will be used for completing of Form I-9.
I authorize investigation of all statements contained in this application. I affirm that all information contained in this application is true and complete and that any misrepresentation, falsification, or willful omission herein shall be sufficient reason for dismissal without any previous notice and/or refusal of employment. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract. I also understand that (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations. I understand that, in connection with the routine processing of your employment application, the Company may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, the Company, will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act. I further understand that my employment with the Company shall be introductory for a period of sixty (60) days, and further that at any time during the introductory period or thereafter, my employment relation with the Company is terminable at will for any reason by either party. BY SUBMITTING THIS FORM YOU ARE AGREEING TO THE TERMS STATED ABOVE. This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications. Thank you for completing this application form and for your interest in St. Michael's
