Job Application - Oceana Medical Care Facility

POSITION APPLIED FOR *

Have you ever filed an application with us before? *

Yes
No

Were you referred to us by an employee? *

Yes
No

Name *

First

Middle

Last

Address: (Street) *

CIty *

State *

Zip Code *

Telephone No. *

Email Address *

Specify any days or times you are not available for work: *

What shift(s) are you willing to work? *

Salary Expectation *

Per *

What shift(s) are you willing to work? *

Employment Status Desired *

Full Time
Part Time

Have you ever been employed by the Oceana County Medical Care Facility? *

Yes
No

Are you a U.S. Citizen? *

Yes
No

What prompted your application? *

Do you have a telephone at your residence? *

Yes
No

Do you have a reliable form of transportation available to you to go to and from work? *

Yes
No

MILITARY SERVICE

Service

Branch

Date of Service

From

To

Were you honorably discharged?

Yes
No

Reserve Status

EMPLOYMENT HISTORY-

List your last four employers, or all employers for the last ten years, whichever is greater. Attach additional signed sheets if necessary. Also list and explain any period(s) of unemployment. Please answer all inquiries. “See Resume” is not acceptable.

Employer’s Name *

Dates Worked (month and year)

From *

To *

Address (Street, City, State and Zip Code) *

Telephone *

Supervisor (Name & Title) *

Your Title *

Your Salary *

Duties & Responsibilities *

Reason for leaving *

2

Add employer (2)

Are you currently on “layoff” status and subject to recall? *

Yes
No

Have you ever been discharged by an employer or resigned in lieu of discharge? *

Yes
No

Have you ever been disciplined (other than discharged by an employer? *

Yes
No

Do you have a valid driver’s license? *

Yes
No

EDUCATION

High School *

Location *

Degrees *

Business School *

Location *

Degrees *

College/University *

Location *

Degrees *

Trade/Vocational School *

Location *

Degrees *

Extracurricular activities & honors received in school *

PROFESSIONAL LICENSES, REGISTRATIONS, AND/OR CERTIFICATIONS

List all states in which you are or have been licensed or certified and any national certifications. *

Attach additional pages if necessary. *

Click or drag files to this area to upload. You can upload up to 10 files.

Have you ever had any professional license or certification placed under investigation, disciplined, suspended, revoked or put on probation? *

Yes
No

Have you ever been denied a license or certification? *

Yes
No

MISCELLANEOUS

Do you have any felony charges pending against you? *

Yes
No

Have you ever been convicted or pled guilty or nolo contendere to a crime? *

Yes
No

Are you 18 years of age or older? *

Yes
No

Are you able to perform the duties of the job for which you have applied? *

Yes
No

References: Give the name, address and telephone numbers of three references who are not related to you.

Reference 1

NAME

ADDRESS

TELEPHONE NO.

EMAIL

Reference 2

NAME

ADDRESS

TELEPHONE NO.

EMAIL

Reference 3

NAME

ADDRESS

TELEPHONE NO.

EMAIL

CERTIFICATION

I understand that I may be required to submit to a physical examination, which may include a drug test, prior to beginning employment and that I must satisfactorily pass such an examination to obtain employment.
I have read and fully understand the questions on this application for employment. I have completely, truthfully, and accurately answered each and every question to the best of my knowledge. I understand that all the inquiries on this application are subject to verification and authorize any schools that I have attended, licensing and certification boards, law enforcement agencies and current and previous employers to release any requested information to the Facility. I also specifically waive written notice from any and all former employers regarding their disclosure to the Facility of any prior disciplinary action and waive any claim against the Facility and current or former employers arising from such investigation of disclosure. I understand that any misrepresentation of the information I have supplied or failed to supply can result in a rejection of this application or, if I have been hired, an immediate dismissal at the sole discretion of the Facility. I understand and agree that in the absence of an express written contract or agreement to the contrary, signed by an authorized representative of the Facility and by me or my authorized representative, any employment I accept shall be for an indefinite term and may be terminated at any time with or without cause either by me or at the will and sole discretion of the Facility regardless of any contrary provisions in any other forms, manuals, handbooks or other documents. Similarly, such employment shall be at the wages, benefits, hours and conditions as the Facility may determine and change from time to time and I agree to abide by any rules, regulations, policies and procedures that may be established from time to time. I understand that no one, other than an authorized representative of the Facility has any authority to enter into an agreement with me contrary to the provisions of this paragraph and that any such agreement must be in writing and signed by such authorized representative or it shall not be effective. It is with full understanding and agreement with the provisions of this Certification that I will accept any employment offered to me.

Signature of Applicant *

Date *