| Current Job Openings |
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Application For Employment |
| Position
Applied For: |
Required. |
| Date
Available: |
Required.Invalid format. |
| Seeking: |
FT |
PT |
TEMP |
| Shift
Preferred: |
Day |
Evening |
Night |
| Salary
Desired: |
Required. |
| Home Phone: |
Required. |
| Business
Phone: |
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| Referral
Source: |
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Personal Information |
| Last Name,
First Name, Middle Initial: |
Required.
Required.
Required. |
| SSN: |
Required.Invalid format. |
| E-mail: |
A value is required.Invalid format. |
| Street
Address: |
Required. |
| City / State
/ Zip: |
Required.
Required.
Required.Invalid format. |
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| Is
there any reason you cannot perform the duties and responsibilities of
the job during the next year? |
Yes
No |
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| If
yes, please explain: |
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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: |
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| Which
Department?: |
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| List
the names of relatives employed by St. Francis Specialty Hospital, Inc: |
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| Relationship: |
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| 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: |
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Who
should we notify in case of an emergency? |
| Name: |
Required. |
| Phone
Number: |
Required. |
| Street
Address: |
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| City / State
/ Zip: |
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Education |
| High
School: Number of Years Completed: |
NA
1
2
3
4 |
| Graduation
Date: |
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| School: |
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| City
/ State |
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| College:
Number of Years Completed: |
NA
1
2
3
4
5
6 |
| School: |
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| City
/ State: |
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| Degree
Earned: |
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| Dates
of Attendance: |
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| Graduate
School: Numbers of Years Completed |
NA
1
2
3
4
5
6 |
| City
/ State: |
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| Degree
Earned: |
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| Dates
of Attendance: |
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Professional/Technical,
& Other Non-Nursing Applicants |
| School
or Special Training: |
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| Length
of Program: |
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| City
/ State |
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| Dates
of Graduation: |
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| List
the registration number and expiration date of any professional,
technical, or occupational license you hold: |
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| Area
of Study: |
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| Typing: |
WPM |
| Shorthand: |
WPM |
| Medical
Terminology?: |
Yes
No |
| List
any office equipment you can operate: |
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| Do
you have any area of specialization or major interest?: |
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|
Nursing Applicants Only |
| Current
License Number: |
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| State: |
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| Check
One if Applicable: |
Registered
Nurse,
Licensed
Practical Nurse,
Other |
| Basic
Nursing Program: |
Diploma,
A.D.,
B. S. |
| Length
of Program: |
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| Date
of Graduation: |
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| School
of Nursing: |
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| Street
Address: |
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| City
/ State: |
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| Advanced
Nursing Preparation |
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| College/University: |
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| Dates
Attended: |
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| Degree
(Major) |
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| Do
you have any area of specialization or major interest? |
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| 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: |
Required. |
| Occupation
/ Organization: |
Required.
Required. |
| Street
Address: |
Required. |
| City
/ State |
Required.
Required. |
| Phone
Number: |
Required. |
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| Name: |
Required. |
| Occupation
/ Organization: |
Required.
Required. |
| Street
Address: |
Required. |
| City
/ State |
Required.
Required. |
| Phone
Number: |
Required. |
|
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:
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| Name
of Employer: |
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| Phone
Number: |
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| Street
Address: |
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| City
/ State: |
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| Job
Title: |
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| Salary
(Start & Final): |
Start
Final |
| Job
Duties: |
FT
PT |
| Name
of Supervisor: |
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| Reason
for Leaving: |
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| May
We Contact Employer?: |
Yes
No |
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| From
MO/YR:
|
To
MO/YR:
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| Name
of Employer: |
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| Phone
Number: |
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| Street
Address: |
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| City
/ State: |
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| Job
Title: |
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| Salary
(Start & Final): |
Start
Final
|
| Job
Duties: |
FT
PT |
| Name
of Supervisor: |
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| Reason
for Leaving: |
|
| May
We Contact Employer?: |
Yes
No |
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| From
MO/YR:
|
To
MO/YR:
|
| Name
of Employer: |
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| Phone
Number: |
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| Street
Address: |
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| City
/ State: |
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| Job
Title: |
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| Salary
(Start & Final): |
Start
Final |
| Job
Duties: |
FT
PT |
| Name
of Supervisor: |
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| Reason
for Leaving: |
|
| May
We Contact Employer?: |
Yes
No |
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| From
MO/YR:
|
To
MO/YR:
|
| Name
of Employer: |
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| Phone
Number: |
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| Street
Address: |
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| City
/ State: |
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| Job
Title: |
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| Salary
(Start & Final): |
Start
Final |
| Job
Duties: |
FT
PT |
| Name
of Supervisor: |
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| 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. |
Required.
|
| Desired
Password: |
Required. |
| Confirm
Password: |
Required. |
Please read the following statements: They constitute the conditions under which you would be employed by St. Francis Specialty Hospital, Inc. should you be accepted for employment.
- 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.
- I authorize the persons, schools, law enforcement agencies, and other organizations or employers named in this application to provide St. Francis Specialty hospital, Inc. with any relevant information that may concern my employment with the Specialty Hospital.
- I understand and agree that:
- Any withholding of information or making false statements on this application or on St. Francis’ medical forms could result in rejection for employment or if employed, termination from the Specialty Hospital.
- Although management makes every effort to accommodate individual preferences, business needs may at times make the following conditions mandatory: overtime, shift changes, a rotating work schedule or a work schedule other than Monday through Friday. I understand and accept these as conditions of my continuing employment.
- A medical examination and signed release statements as stipulated by the Specialty Hospital are required. Results will be held in confidence by the Employee Health Department except where release of such information is required by law.
- All employees are on a trial basis during the first three months of employment.
- Termination with or without cause and with or without notice, at any time, is an option of the Specialty Hospital.
- I agree to abide by the policies, rules and regulations as set forth in the Specialty Hospital’s employees’ handbook (and as it may be revised).
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I agree
Required.
Initials
Required. |
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