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ORHC - Visitors and Cusomers

NAME

First
Middle
Last

PRESENT ADDRESS

Street
City
State
 Zip
Telephone
E-mail Address

 Position(s) applied for
 Departments of Interest:
 How did you hear of our opening? Paper Internet: Associate Other
 Check shifts you are willing to work: Days Evenings Nights Weekend
 Would you work: Full Time? Part Time?   Can you rotate two shifts?
Date available for work

Were you previously employed by us? Yes No       If yes, when
Have you ever been discharged from a job? Yes No
If yes, list employer, dates, reason and explanation
    
Have you ever been excluded from Medicare, Medicaid, or any other state or federal programs? Yes No
A conviction record will not necessarily disqualify an applicant from employment. Do you have a record of founded child or dependent adult
   abuse or have you ever been convicted of a crime, in this state or any other? Yes No
If yes, explain and give dates:
    
Are there any other skills which you feel would especially fit you for work with our organization?
    

I am a U.S citizen Yes No       If you are not a citizen are you legally eligible for employment in the U.S.A.? Yes No
Are you authorized to work for any employer, or only your current one? Any Current
Have you graduated from High School? Yes No GED & Where?
Are you at least age 16? Yes No

EDUCATION
 
Name and Address of School
Course(s) of Study
Select Last Completed Year
Did You Graduate?
Diploma or Degree
College
Name
Street
City
State
 Zip

1 2
3 4

 Yes
No

Other
(Specify)

Type
Name
Street
City
State
 Zip
1 2
3 4		 Yes
No
Professional License / Certificate No.
Type / State


PERSONAL REFERENCES (Not Former Employers or Relatives)
Name #1
Street
City
State
 Zip
Telephone
Occupation
Name #2
Street
City
State
 Zip
Telephone
Occupation
Name #3
Street
City
State
 Zip
Telephone
Occupation
LIST ALL PRESENT AND PAST EMPLOYERS (Beginning with your most recent)
Company #1
 From / (Month / Year)
Street
 To     / (Month / Year)
City
 Describe Work Performed
State
 Zip
Telephone
 Reason For Leaving   
Company Type
 Hourly Starting Salary
Supervisor
 Hourly Ending Salary 
Company #2
 From / (Month / Year)
Street
 To     / ( Month / Year)
City
 Describe Work Performed
State
 Zip
Telephone
 Reason For Leaving   
Company Type
 Hourly Starting Salary
Supervisor
 Hourly Ending Salary 
Company #3
 From / (Month / Year)
Street
 To     / (Month / Year)
City
 Describe Work Performed
State
 Zip
Telephone
 Reason For Leaving   
Company Type
 Hourly Starting Salary
Supervisor
 Hourly Ending Salary 
Company #4
 From / (Month / Year)
Street
 To     / (Month / Year)
City
 Describe Work Performed
State
 Zip
Telephone
 Reason For Leaving   
Company Type
 Hourly Starting Salary
Supervisor
 Hourly Ending Salary 

May We Contact the Employers Listed Above? Yes No
If not, indicate which one(s) you do not wish us to contact.

Have You Ever Served in the U.S. Armed Forces? Yes No
List Areas of Training:

PLEASE NOTE

Ottumwa Regional Health Center operates 24 hours a day, seven days a week. Assignments of shifts, hospital units, days off and other conditions of employment are generally made on basis of availability, tenure, and ability in each job classification. Each employee is required to comply with staffing assignments. As work changes occur within departments or hospital wide, employees may be required to change shifts and/or days worked temporarily, or on a regular basis.

I certify that the information contained in this application is correct to the best of my knowledge and understand that falsification of this information is grounds for refusal to hire or, if hired, dismissal. I authorize any of the persons or organizations referenced in this application to give you any and all information concerning my previous employment, education, or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application and release all such parties from all liability for any damage that may result from furnishing such information to you. I authorize you to request and receive such information. In consideration for my employment and my being considered for employment by your company, I agree to conform to the rules and regulations of the company and acknowledge that these rules and regulations may be changed, interpreted, withdrawn, or added to by your company at any time at the company's sole option and without any prior notice to me. I further acknowledge that my employment maybe terminated, and any offer of employment, If such is made, may be withdrawn, with or without cause, and with without prior notice, anytime, at the option of the company or myself. I understand that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or assure or make some other personnel move, either prior to commencement of employment or after I have become employed, or assure any benefits or terms and conditions of employment, or make any agreement contrary to the foregoing. I acknowledge that l have been advised that this application will remain active for no more than 90 days from the date it was made.

I further understand that this hospital follows the "fair employment practice code" and there is no discrimination in the hiring of individuals based on sex, race, religion, age, or physical or mental handicap unrelated to ability to perform the work required. I understand if I am employed it will be on a probationary or trial basis for a period of 90 days and will then be considered a regular employee under Health Center policy. Applicants will be required to submit to a pre employment test to detect the presence of alcohol or a controlled substance.

I agree to follow the Standards of Behavior in all aspects of my work

If you can affirm the statements above and have read and understood the application policy
please enter your full name

 

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