Arkansas Continued Care Hospital Job Application

Personal

Name

First Middle Last

Address

Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Alternate Phone

Email

Position applying for

Date available for work:

Would you accept:

Full Time
Part Time
PRN
Weekends
Any

Shift availibility:

Select All
Day Shift
Evening Shift
Night Shift
Rotating Shift
7 am - 7 pm
7 pm - 7 am

Are you at least 18 years of age?

Yes
No

Are you related to or a member of the same household of a current employee?

Yes
No

If yes, list names and relationship.

Were you referred by a current employee?

Yes
No

If yes, employee name:

Do you have the legal right to work in the United States in the job for which you are applying? (Proof of eligibility to work in the United States)

Yes
No

Have you ever been convicted of a crime (felony or misdemeanor), or are you now under any investigation for a violation of criminal law? (A conviction or investigation will not necessarily disqualify you from employment; however, failure to disclose a criminal conviction or investigation may disqualify you from employement.)

Yes
No

If yes, please explain:

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?

Yes
No

Have you ever been subject of any adverse action(s) by any duly authorized sanctioning or disciplinary agency for either conduct based or performance based actions?

Yes
No

If yes, please explain:

Have you served in the U.S. Armed Forces?

Yes
No

From	To	Branch

Education

High School

School Name	City and State	Graduate?

Business/Trade/Technical Schools

School Name	City and State	Major/Minor	Graduation Date	Degree Received

Undergraduate College/University

School Name	City and State	Major/Minor	Graduation Date	Degree Received

Graduate College/University

School Name	City and State	Major/Minor	Graduation Date	Degree Received

Work History

List previous employers for whom you have worked over the last seven years, beginning with the most recent employer. List any other employment that reflects experience related to the job for which you are applying.

1 - Current or most recent company name:

Company Phone

Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employed (month and year)

From	To

Name of Supervisor

First Last

Supervisor's Title

Pay

Beginning	Ending

Your job title and primary duties:

Reason for leaving:

May we contact this employer prior to extending an offer of employment?

Yes
No

2 - Company name:

Company Phone

Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employed (month and year)

From	To

Name of Supervisor

First Last

Supervisor's Title

Pay

Beginning	Ending

Your job title and primary duties:

Reason for leaving:

May we contact this employer prior to extending an offer of employment?

Yes
No

3 - Company name:

Company Phone

Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employed (month and year)

From	To

Name of Supervisor

First Last

Supervisor's Title

Pay

Beginning	Ending

Your job title and primary duties:

Reason for leaving:

May we contact this employer prior to extending an offer of employment?

Yes
No

4 - Company name:

Company Phone

Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employed (month and year)

From	To

Name of Supervisor

First Last

Supervisor's Title

Pay

Beginning	Ending

Your job title and primary duties:

Reason for leaving:

May we contact this employer prior to extending an offer of employment?

Yes
No

Licensure-Registration-Certification Information

Please list any professional licenses, registrations, or certifications which have been issued to you:

Name	State	Number	Year Issued	Current?	Expiration Date

If currently eligible for license, registration, or certification please indicate status and date here:

Has your license, registration, or certification in this state or another state been suspended, limited, revoked or subjected to disciplinary action? If yes, please explain.

Additional Certifications:

CPR
BLS
ACLS
BLS Instr.

Professional Membership Information

Please list any professional organization to which you subscribe or are a member:

Foreign Language Information

Please list any foreign language skills in which you are fluent in speaking and/or writing.

Professional References

Please list two (2) business/professional references (not relatives or co-workers)

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Source Information

The following information is requested to assist us in assessing the effectiveness of our recruiting activities. Your cooperation is appreciated. Tell us how you learned about this position opening.

Applicant Acknowledgements

By submitting this information for employment I, the applicant, certifiy that the information given by me in this employment inquiry is true, correct, and complete. If employed, I acknowledge and understand that:

Any misstatement or omission of fact on this application may result in my 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 pre-employment 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 (5-7) 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 malpractive suit or arbitration action; any adverse action by a state licensing board; a conviction of any felony or a 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 Arkansas Continued Care Hospital is an employer at will, which means that my employment is not for definite term and that either the hospital or I will have the right to terminate the employment relationiship at any time, with or without cause or notice. I also understand that this tatus can only be altered by a written contract of employment that is specific as to all material terms and is signed by ther Arkansas Contued Care Hospital President and me.

Upon termination, to return in good condition any company property issued to me or to allow for the value of same, plus any outstanding accounts, to be deducted from my wages.

I hereby authorize Arkansas Continued Care Hospital 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 Arkansas Continued Care Hospital withot delay.

As required by the Fair Credit Reporting Act, notice is give 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 relative to criminal charges. A credit report will not be requested unless it is deemed pertinent to the functions of the position for which you are applying.
If you are denied employment, either wholly or partly, because of the information contained in a consumer report, a disclosure will be made to you of the name and address of the consumer reporting agency making such a report.

Application

TEST

Arkansas Continued Care Hospital Job Application

Personal

Education

Work History

Licensure-Registration-Certification Information

Professional Membership Information

Foreign Language Information

Professional References

Source Information

Applicant Acknowledgements