Full Name
*
First Name
Last Name
SSN
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
Phone
(###)
###
####
Would you be available for
Check all that apply
Shifts you can work
Check all that apply
Are you at least 18 years of age?
Are you related to or a member of the same household of a current employee?
If yes, list name(s) and relationship:
(Includes spouse, children, parents, in-laws, siblings, legal dependents, members of the same residence, or any person who fulfills an immediate role for you).
Were you referred by a current employee?
If yes, name employee:
Do you have a legal right to work in the United States in the job which you are applying for?
Date available for work
MM
DD
YYYY
Have you ever been convicted of a crime (felony or misemeanor), or are you now under any investigation for a violation of criminal law?
If yes, please explain
(a conviction or investigation will not necessarily disqualify you from employment; however, a failure to disclose a criminal conviction or investigation may disqualify you from employment).
Have you ever been excluded, suspended, or debarred from, or otherwise declared ineligible to provide services in the Medicare or Medicaid programs, or any other federally-funded health care program?
Have you ever been subject to any adverse action(s) by any duly authorized sanctioning or disciplinary agency for either conduct based or performance based actions?
If yes, please explain:
Have you served in the U.S. Armed Forces?
If yes, please explain your dates of service & the branch in which you served
Do you use tobacco in any form, including e-cigarettes?
All candidates for hire are nicotine tested
Area of Study/Minor/Major
Did you graduate?
Graduation Date Degree Received (Highest Degree)
MM
DD
YYYY
Any other education details?
Reference #1 Name
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Reference #2 Name
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
#1 – Current or most recent employer
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Supervisor's name/title
Job Title(s)/Duties
Beginning and Ending Employment Dates
Beginning & Ending Pay $
Reason for leaving (if applicable)
May we contact this employer?
#2 – Next most recent employer
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Supervisor Name & Title
Job Title(s)/Duties
Beginning & Ending Employment Dates
Beginning & Ending Pay $
Reason for leaving
May we contact this employer?
#3 – Next most recent employer
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Name & Title of Supervisor
Job Title(s) & Duties
Beginning & Ending Employment Dates
Beginning & Ending Pay $
Reason for leaving
May we contact this employer?
#4 – Next most recent employer
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Supervisor's Name & Title
Job Title(s) & Duties
Beginning & Ending Employment Dates
Beginning & Ending Pay $
Reason for Leaving
May we contact this employer?
License/Registration/Certification #1
Include NAME & NUMBER of license/ registration/certification, as well as the STATE & the YEAR it was issued in.
Current?
Expiration Date
MM
DD
YYYY
License/Registration/Certification #2
Include NAME & NUMBER of license/registration/certification, as well as the STATE & the YEAR it was issued in.
Current?
Expiration Date?
MM
DD
YYYY
License/Registration/Certification #3
Include NAME & NUMBER of license/registration/certification, as well as the STATE & the YEAR it was issued in.
Current?
Expiration Date?
MM
DD
YYYY
License/Registration/Certification #4
Include NAME & NUMBER of license/registration/certification, as well as the STATE & the YEAR it was issued in.
Current?
Expiration Date?
MM
DD
YYYY
If currently eligible, please indicate status & date here:
Has your licenses, registrations, or certifications in this state or another state been suspended, limited, revoked, or subjected to disciplinary action?
If yes, please explain:
Any additional CURRENT certifications?
Please list any professional organization to which you subscribe or are a member:
Please list any foreign language skills in which you are fluent
List the language(s) and if you can speak, read or write fluently.
The following information is requested to assist us in assesing the effectiveness of our recruiting activities. Your cooporation is apprecaited. How did you hear about us?
Please check all that apply.
I CERTIFY THAT THE INFORMATION GIVEN BY ME IN THIS EMPLOYMENT INQUIRY IS TRUE, CORRECT, AND COMPLETE. IF EMPLOYED, I ACKNOWLEDGE THAT:
•Any misstatement or omission of fact on this application may result in dismissal.
•I must submit acceptable evidence of my right to work in the United States.
•Our facilities are tobacco free and use of all tobacco products is prohibited on company property.
•Our facilities are drug free workplaces. I may be asked and I must take and pass a drug test that screens for illegal
drugs and unauthorized controlled substances; remain free of illegal drugs, alcohol, abusive levels of prescription
drugs at work; and comply with the Drug and Alcohol Use/Abuse Workplace policies.
•I understand that refusal to submit to a drug test due to reasonable suspicion, or failing a drug test is grounds for
termination.
•Any personal property carried by me, to and from the hospital, including my handbag, briefcase or packages, may
be inspected by authorized hospital personnel. I understand that any storage area provided to me on hospital
property may be inspected by the hospital.
•I will be required to comply with all hospital and corporate policies and procedures.
•I authorize this application to be viewed by any affiliated corporations.
•I agree to notify the organization in writing within five to seven days of receiving any written or oral notice of any
adverse action, including, without limitation, exclusion from participation in any federal or state health care or
procurement programs, any filed and served malpractice suit or arbitration action; any adverse action by a state
licensing board; a conviction of any felony or misdemeanor of moral turpitude; any action against any certification
under Medicare or Medicaid programs; or any cancellation, non renewal or material reduction in medical liability
insurance policy coverage. Also understand that I am required to report such conduct to the Director of Human
Resources.
•I understand that ARCCH is an employer at will, which means that my employment is not for a definite term and
that either the hospital or I will have the right to terminate the employment relationship at any time, with or without
cause or notice. I also understand that this status can only be altered by a written contract of employment that is
specific as to all material terms and is signed by the ARCCH President and me.
•Upon termination, to return in good condition, any company property issued to me or to allow for the value of the
same, plus any outstanding accounts, is to be deducted from my wages.
•I hereby authorize ARCCH to confirm the information that appears in my application for employment and
authorize all former employers, universities or colleges, references, credit and government agencies, or other
persons, firms, corporations and institutions to provide such information to ARCCH without delay.
As required by the Fair Credit Reporting Act, notice is given that a consumer report may be made in
connection with your application of employment. A consumer report may consist of employment records,
educational verification, licensure verification, driving history, previous addresses and other public
records related to criminal charges. A credit report will not be requested unless it is deemed pertinent to
the function of the position for which you are applying.
If you are denied employment, either wholly or partly, because of information contained in the consumer
report, a disclosure will be made to you of the name and address of the consumer reporting agency
making such report.
Date of Signature
MM
DD
YYYY
