Position applying for (required)
Are you applying for: (required)
Full TimePart TimePer Diem
What shifts are you available to work? (required)
Are you employed now? (required)
When would you be available to start work? (required)
I realize the staffing needs of the Medical Center may require me to work extra days or take low census days. (required) I accept
Do you have the legal right to work and be employed in the U.S.? (required) YesNo
Are you 18 years of age or older? (required) YesNo
I understand that if an offer of employment is made, I am required to furnish proof that I have the legal right to work in the U.S. (required)
If related to anyone in our employ, please state name and department
Have you ever worked for Glenn Medical Center? YesNo
If yes, what department and/or site? Under what name?
Professional License Number
Type of License
Have you ever received any disciplinary actions against your license or certification in this or any other state? YesNo
If yes to above question, please explain
NOTE: If you respond yes to this question, it will not automatically bar you from employment. Each circumstance will be decided on a case by case basis to determine whether or not it is relevant to the position for which you are applying.
Please check the skills you possess that are relevant to the position for which you are applying. Unrelated items may be checked at your discretion.
FilingTypingLetter CompositionPersonal ComputerPayrollAccounts payable / ReceivableInsurance BillingSwitchboardWord Professing SoftwareAdmittingMedical TerminologyBiomedical EquipmentOther
If you selected typing, what is your WPM?
If you selected Word Processing Software, what software are you familiar with?
If you selected Data Processing Equipment, what type are you familiar with?
If you selected Other skills, please explain
Bilingual Ability: (languages)
I understand that if my bilingual skills are needed, I may be asked to interpret occasionally. I agree
Specify the number of months of actual work experience:
Critical care / telemetry
Geriatric Skilled Nursing
UR / case management
OB: L&DD / PP / NICU
Other (specify number of months and services performed)
If you have these certifications / Memberships, type the expiration date
High school: name and location of school
Number of years attended
Degree or Certification
College, Vocational, Tech: name and location of school 1
College, Vocational, Tech: name and location of school 2
College, Vocational, Tech: name and location of school 3
List memberships in professional organizations which you feel would enhance your application, excluding any whose name would indicate your sex, race, religion, color, national origin, ancestry, age, medical condition, physical disability, mental disability, or marital status.
Give a complete EMPLOYMENT RECORD for the last seven years starting with present or last employer; include periods of unemployment. You may submit a resume, but the entire application MUST be completed. Please use the additional information section at the end of the application if needed.
May we contact your present employer? YesNo
Employment Record 1
City, State, and Zip Code
Reason for Leaving
Start of Employment
End of Employment
Shift Full timePart timeOn call
Employment Record 2
Employment Record 3
Have you ever been involuntarily terminated from any prior employment? YesNo
If you have been involuntarily terminated from any prior employment, give the reason for termination and employer's name
Please provide the names of two persons not related to you, whom you have known at least one year.
Additional Information (you may include employment records, or information not mentioned in other questions)
Note: In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, age, disability, religion, sex, and familial status. (Not all prohibited bases apply to all programs.) To file a complaint of discrimination, write: USDA, Director, Office of Civil Rights, 1400 Independence Avenue S.W., Washington, D.C. 20250-9410. Or, call (800) 895-3282 (voice) or (202) 720-6382 (TDD) This institution is an equal opportunity provider and employer.
(required) I hereby certify that the information on this application is correct and complete to the best of my knowledge. I agree to have any of the statements checked by the Medical Center unless I have indicated to the contrary. I authorize the references listed above to provide the Medical Center any and all information concerning my previous employment and other pertinent information that they may have. Further, I release all parties and persons from any and all liability for any damages that may result from furnishing such information to the Medical Center as well as from the use or disclosure of such information by the Medical Center or any of its agents, employees, or representatives. I understand that falsification or omission of any information on this application may result in the withdrawal of a job offer or, if I have been hired, immediate dismissal.
(required) If I am employed by the Medical Center, I agree to conform to its rules and regulations. I understand employment is based on the mutual con. sent of the employee and the Medical Center. Accordingly, with or without cause or advance notice, either I or the Medical Center can terminate the employment relationship at will, at any time. I further understand that no employee or representative of the Medical Center, other than the Chief Executive Officer, has the authority to enter into any agreement for employment for any specified period of time, or to make any express or implied agreement contrary to the foregoing.
(required) I understand that all offers of employment are conditioned on satisfactory responses to reference requests, proof of identity, and legal right to work in the U.S., successful completion of a background check, and satisfactory completion of a post offer medical examination. Medical examination includes laboratory testing of a urine sample from a prospective employee to determine the presence of certain drugs and/or alcohol in the body. The medical examination will be at the Medical Center's expense.
Applicant Signature (required) - Please type your first and last name to electronically sign this document
*Make sure all required fields are filled, or the send button will not function. If you have issues submitting this form online, please print the completed application and mail it to us, or request a printed application.