St. Francis Specialty Hospital-APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT
Position Applied For:
Date Available:
Seeking:	FT	PT	TEMP
Shift Preferred:	Day	Evening	Night
Salary Desired:
Home Phone:
Business Phone:
Referral Source:

PERSONAL
Last Name, First Name, Middle Initial:
SSN:
Street Address:
City / State / Zip:
Is there any reason you cannot perform the duties and responsibilities of the job during the next year?	Yes No
If yes, please explain:
Are you 18 years old or older?	Yes No
Have you ever worked for St. Francis Specialty Hospital, Inc.?	Yes No
If yes, year terminated:
Which Department?:
List the names of relatives employed by St. Francis Specialty Hospital, Inc:
Relationship:
Are you either a United States citizen or an alien who has the legal right to work in the job for which you are applying?	Yes No
Have you, since the age of 18, ever been convicted of a felony?	Yes No
If yes, please explain:
Who should we notify in case of an emergency?
Name:
Phone Number:
Street Address:
City / State / Zip:

EDUCATION
High School: Number of Years Completed:	NA 1 2 3 4
Graduation Date:
School:
City / State

College: Number of Years Completed:	NA 1 2 3 4 5 6
School:
City / State:
Degree Earned:
Dates of Attendance:

Graduate School: Numbers of Years Completed	NA 1 2 3 4 5 6
City / State:
Degree Earned:
Dates of Attendance:

PROFESSIONAL/TECHNICAL, & OTHER NON-NURSING APPLICANTS
School or Special Training:
Length of Program:
City / State
Dates of Graduation:
List the registration number and expiration date of any professional, technical, or occupational license you hold:
Area of Study:
Typing:	WPM
Shorthand:	WPM
Medical Terminology?:	Yes No
List any office equipment you can operate:
Do you have any area of specialization or major interest?:

NURSING APPLICANTS ONLY
Current License Number:
State:
Check One if Applicable:	Registered Nurse, Licensed Practical Nurse, Other
Basic Nursing Program:	Diploma, A.D., B.S.
Length of Program:
Date of Graduation:
School of Nursing:
Street Address:
City / State:

Advanced Nursing Preparation
College/University:
Dates Attended:
Degree (Major)
Do you have any area of specialization or major interest?

Give the name(s) of persons, not related to you, that we may contact to verify your qualifications for the position. New Graduates, please list professors or clinical instructors.
Name:
Occupation / Organization:
Street Address:
City / State
Phone Number:

Name:
Occupation / Organization:
Street Address:
City / State
Phone Number:

EMPLOYMENT RECORD
Account for full time or part time employment, even if resume is included. Account for all periods of unemployment.
From MO/YR:		To MO/YR:
Name of Employer:
Phone Number:
Street Address:
City / State:
Job Title:
Salary (Start & Final):	Start Final
Job Duties:	FT PT
Name of Supervisor:
Reason for Leaving:
May We Contact Employer?:	Yes No

From MO/YR:		To MO/YR:
Name of Employer:
Phone Number:
Street Address:
City / State:
Job Title:
Salary (Start & Final):	Start Final
Job Duties:	FT PT
Name of Supervisor:
Reason for Leaving:
May We Contact Employer?:	Yes No

From MO/YR:		To MO/YR:
Name of Employer:
Phone Number:
Street Address:
City / State:
Job Title:
Salary (Start & Final):	Start Final
Job Duties:	FT PT
Name of Supervisor:
Reason for Leaving:
May We Contact Employer?:	Yes No

From MO/YR:		To MO/YR:
Name of Employer:
Phone Number:
Street Address:
City / State:
Job Title:
Salary (Start & Final):	Start Final
Job Duties:	FT PT
Name of Supervisor:
Reason for Leaving:
May We Contact Employer?:	Yes No
Briefly describe the type of work for which you are qualified. Note any details about your qualifications which should be considered. Include special skills, machines operated, professional affiliations, honors and awards, publications etc. You may omit those which indicate your race, religious creed, color, national origin, ancestry, sex age, physical or mental impairment or medical condition, or veteran status.

Desired Password:
Confirm Password:
The information that I have provided on this application is accurate to the best of my knowledge and subject to validation by St. Francis Specialty Hospital, Inc. Please place a check in the checkbox below to agree to the previous statement.
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