Are you applying for: (required)

What shifts are you available to work? (required)

Are you employed now? (required)
YesNo

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)

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)



Personal Data

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 & Technical Applicants Only

Professional License Number

Type of License

Expiration Date

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.



Skills

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



Nursing Positions Only

Specify the number of months of actual work experience:

Emergency services

Critical care / telemetry

Perioperative

Homecare Services

Oncology

Pediatrics

Gastroenterology

Medical Surgical

Geriatric Skilled Nursing

Rehabilitation

Catheterization Lab

UR / case management

OB: L&DD / PP / NICU

Ambulatory Services

Other (specify number of months and services performed)

If you have these certifications / Memberships, type the expiration date

BLS

ACLS

CCRN

MICN

AORN

NRP

PALS



Education

High school: name and location of school

Date graduated

Number of years attended

Major Course

Degree or Certification


College, Vocational, Tech: name and location of school 1

Date graduated

Number of years attended

Major Course

Degree or Certification


College, Vocational, Tech: name and location of school 2

Date graduated

Number of years attended

Major Course

Degree or Certification


College, Vocational, Tech: name and location of school 3

Date graduated

Number of years attended

Major Course

Degree or Certification

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.



Employment

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

Company Name

Street Address

City, State, and Zip Code

Phone Number

Supervisor

Job Title

Job Duties

Reason for Leaving

Start of Employment

End of Employment

Shift Full timePart timeOn call

Hours Worked


Employment Record 2

Company Name

Street Address

City, State, and Zip Code

Phone Number

Supervisor

Job Title

Job Duties

Reason for Leaving

Start of Employment

End of Employment

Shift Full timePart timeOn call

Hours Worked


Employment Record 3

Company Name

Street Address

City, State, and Zip Code

Phone Number

Supervisor

Job Title

Job Duties

Reason for Leaving

Start of Employment

End of Employment

Shift Full timePart timeOn call

Hours Worked

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



References

Please provide the names of two persons not related to you, whom you have known at least one year.


Reference 1

Name

Address

Phone

Business

Years Acquainted


Reference 2

Name

Address

Phone

Business

Years Acquainted

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.