Claxton-Hepburn Medical Center

Employment Application

Prospective employees will receive consideration without discrimination because of race, creed, color, sex, age, national origin, handicap, Veteran status.

*indicates required information

Last Name:*
First Name:*
Middle Initial:
Email Address:*
Street Address:*
City: *
State: *
ZIP/Postal Code:*
Home Telephone:(*)
Cell Telephone:
Are you over 18 years of age	Yes No
Have you previously worked for this hospital?	Yes No
If yes, month and year:
Department:
POSITION APPLYING FOR:
How did you hear about this position?
Are you legally eligible for employment in the United States? If not, please explain.	Yes No
Are you able to perform the primary function of the position applied for, with or without reasonable accommodation?	Yes No
Indicate special qualifications or skills:
Will you work:	Full Time Part Time Per Diem Days Evenings Nights Seasonal 12-Hour Shifts Overtime
If you indicated part time employment, please specify the number of hours you are available.
When will you be available to begin work?
Education and Training
Graduate School
Name of School
Location (City, State)
Major
Degree
Number of years completed
Did you graduate?	Yes No
College
Name of School
Location (City, State)
Major
Degree
Number of years completed
Did you graduate?	Yes No
Business,Trade or Technical School
Name of School
Location (City, State)
Major
Degree
Number of years completed
Did you graduate?	Yes No
Membership in professional or civic organizations (Exclude those which may disclose your race, color, religion, national origin, gender or age.)
If a professional license or certification is required for the position for which you are applying, please complete below:
N.Y.S. License/Certificate Information:
License/Certification Number:
Registration Expiration Date:
I am not yet licensed in New York State and plan to:	Take N.Y.S. Boards
Date:
I plan to:	Apply for reciprocity
Date:
Employment/Military Service
Please provide us with your employment history starting with your present or most recent employer; include at least the last 10 years.

Company Name
Address
Telephone
May we contact this employer?	Yes No
Name of Supervisor
Employment Start Date
Employment End Date
Starting weekly pay
Ending weekly pay
Job title and describe your work
Reason for leaving
Company Name
Address
Telephone
May we contact this employer?	Yes No
Name of Supervisor
Employment start date
Employment end date
Starting weekly pay
Ending weekly pay
Job title and describe your work
Reason for leaving
Company Name
Address
Telephone
May we contact this employer?	Yes No
Name of supervisor
Employment start date
Employment end date
Starting weekly pay
Ending weekly pay
Job title and describe your work
Reason for leaving
Company Name
Address
Telephone
May we contact this employer?	Yes No
Name of supervisor
Employment start date
Employment end date
Starting weekly pay
Ending weekly pay
Job title and describe work
Reason for leaving
References- Give the names and addresses of five people who know you (not relatives or friends) who can comment on your character, work habits and competency. At least two of your references should be managers or supervisors. (We assume we have your permission to contact these people unless you indicate to the contrary.)
1. Reference Name*
Address
Telephone*
Email address
2. Reference Name*
Address
Telephone*
Email address
3. Reference Name*
Address
Telephone*
Email address
4. Reference Name*
Address
Telephone*
Email address
5. Reference Name*
Address
Telephone*
Email address
Please complete this section in full to be considered for employment.
Have you been convicted of a crime in the past ten years, excluding summary offenses, which have not been annulled, expunged or sealed by a court?	Yes No
If yes, describe in full.
Have you ever been subject to investigation by a professional licensure board?	Yes No
If yes, describe in full.
Have you ever been subject to discipline by a professional or licensure board?	Yes No
If yes, describe in full.
Have you ever been discharged from employment by a healthcare facility?	Yes No
If yes, describe in full.

Type name for acknowledgement*
Date:*

Employment Application

Primary Contact Information