APPLICATION FOR EMPLOYMENT

Green Valley Hospital is an equal employment opportunity employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, sexual orientation, marital status, national origin, disability or handicap, or veteran status.

THIS IS A VERY IMPORTANT DOCUMENT
YOU MUST ANSWER EACH QUESTION FULLY AND ACCURATELY. FAILURE TO DO SO MAY RESULT IN YOUR APPLICATION
NOT BEING CONSIDERED. IF INFORMATION IS LATER FOUND TO BE OMITTED OR INACCURATE ON YOUR APPLICATION
AND IT IS DISCOVERED AFTER YOUR EMPLOYMENT HAS BEGUN, YOU MAY BE TERMINATED FROM EMPLOYMENT.

________________________________
DATE

_________________________________________________________________
FULL PRINTED NAME OF APPLICANT

PLEASE PRINT
PERSONAL INFORMATION
NAME________________________________________________________
LAST

FIRST

SOCIAL SECURITY NUMBER______________

MIDDLE

LIST ALL OTHER NAMES BY WHICH YOU HAVE EVER WORKED OR BEEN EDUCATED:

__________________________________________________________________________________________
(NOTE: THIS INFORMATION IS ONLY NECESSARY FOR VERIFICATION OF YOUR PRIOR WORK HISTORY AND EDUCATION)

PRESENT ADDRESS ____________________________________________________________________________________________
STREET/APT NO.

CITY

STATE

____________________

____________________

______________________

HOME PHONE NUMBER

CELL PHONE NUMBER

ZIP

EMAIL ADDRESS

PREVIOUS ADDRESS ___________________________________________________________________________________________
STREET/APT NO.

CITY

ARE YOU 18 YEARS OR OLDER?
 YES  NO
ARE YOU LEGALLY ELIGIBLE FOR EMPLOYMENT IN THE UNITED STATES?

STATE

ZIP

 YES  NO

EMPLOYMENT DESIRED
POSITION______________________________ DEPARTMENT_______________________
SHIFT__________________
DATE YOU CAN START________________ SALARY DESIRED______________
ARE YOU AVAILABLE TO WORK  FULL TIME?  PART TIME?  PRN?
IF REQUESTED, ARE YOU AVAILABLE TO WORK (Check as many that would apply):
 DAYS
 EVENINGS
 NIGHTS
 WEEKENDS
 OVERTIME
ARE YOU CURRENTLY EMPLOYED?  YES  NO
MAY WE CALL YOUR PRESENT EMPLOYER?  YES  NO
HAVE YOU EVER APPLIED TO GREEN VALLEY HOSPITAL BEFORE?  NO  YES
WHEN?_____________
HAVE YOU EVER WORKED FOR GREEN VALLEY HOSPITAL BEFORE?  NO  YES
DEPT?_______________ WHEN?_____________
WHO REFERRED YOU TO GREEN VALLEY HOSPITAL?______________________________________________________________

EDUCATION
SCHOOL LEVEL
HIGH SCHOOL

NAME AND LOCATION

YEARS COMPLETED

DIPLOMA/DEGREE/COURSE OF STUDY

____________________________________________________________________________________________
____________________________________________________________________________________________
COLLEGE
____________________________________________________________________________________________
____________________________________________________________________________________________
TRADE, BUSINESS ____________________________________________________________________________________________
OR CORRESP. SCHOOL

MISCELLANEOUS
SPECIAL CERTIFICATIONS OR LICENSES (IF ANY) __________________________________________________________________
License Number__________________________ State_________________________
Other Professional Memberships (You need not disclose membership in professional organizations that may reveal information regarding race, color, creed, religion, ancestry, age, sex, sexual orientation, national origin, disability or handicap, or veteran status.)
___________________________________________________________________________________________________________
GREEN VALLEY HOSPITAL MAY OBTAIN INFORMATION ABOUT YOU FROM PUBLIC RECORDS. IF YOU WISH TO WAIVE YOUR RIGHT TO RECEIVE A
COPY OF ANY PUBLIC RECORD, YOU SHOULD CHECK THE FOLLOWING BOX:



FORMER EMPLOYERS (List last 3 employers, starting with the most recent one)
1. NAME AND ADDRESS OF PRESENT OR LAST EMPLOYER__________________________________________________________
________________________________________________________________________________________________

STARTING DATE__________________
MONTH

YEAR

LEAVING DATE__________________
MONTH

JOB TITLE___________________________

YEAR

DESCRIPTION OF WORK_______________________________________________________________________________
STARTING SALARY________________ FINAL SALARY______________ MAY WE CALL YOUR SUPERVISOR?  YES  NO
NAME/TITLE OF IMMEDIATE SUPERVISOR_______________________________
PHONE__________________________
DID YOU LEAVE  VOLUNTARILY  INVOLUNTARILY AND PLEASE STATE THE EXACT REASON(S) FOR LEAVING:___________________
________________________________________________________________________________________________

2. NAME AND ADDRESS OF EMPLOYER_______________________________________________________________________
________________________________________________________________________________________________

STARTING DATE__________________ LEAVING DATE___________________
MONTH

YEAR

MONTH

JOB TITLE__________________________

YEAR

DESCRIPTION OF WORK_______________________________________________________________________________
STARTING SALARY________________ FINAL SALARY______________ MAY WE CALL YOUR SUPERVISOR?  YES  NO
NAME/TITLE OF IMMEDIATE SUPERVISOR_______________________________
PHONE__________________________
DID YOU LEAVE  VOLUNTARILY  INVOLUNTARILY AND PLEASE STATE THE EXACT REASON(S) FOR LEAVING:___________________
________________________________________________________________________________________________

3. NAME AND ADDRESS OF EMPLOYER_______________________________________________________________________
________________________________________________________________________________________________

STARTING DATE__________________ LEAVING DATE___________________
MONTH

YEAR

MONTH

JOB TITLE__________________________

YEAR

DESCRIPTION OF WORK_______________________________________________________________________________
STARTING SALARY________________ FINAL SALARY______________ MAY WE CALL YOUR SUPERVISOR?  YES  NO
NAME/TITLE OF IMMEDIATE SUPERVISOR_______________________________
PHONE__________________________
DID YOU LEAVE  VOLUNTARILY  INVOLUNTARILY AND PLEASE STATE THE EXACT REASON(S) FOR LEAVING:___________________
_________________________________________________________________________________________________

(IF YOU WISH TO DESCRIBE ADDITIONAL WORK EXPERIENCE, ATTACH THE ABOVE INFORMATION
FOR EACH POSITION ON A SEPARATE PIECE OF PAPER.)
UNEMPLOYMENT HISTORY
PLEASE ACCOUNT FOR ANY TIME YOU WERE NOT EMPLOYED IN THE LAST 10 YEARS, AFTER LEAVING SCHOOL (You need not list any unemployed periods of one month or less.)

TIME PERIOD

REASON(S) UNEMPLOYED

___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

(PLEASE ATTACH ADDITIONAL SHEETS, IF INSUFFICIENT SPACE)

PERFORMANCE OF JOB RELATED FUNCTIONS
ARE YOU ABLE TO PERFORM THE ESSENTIAL FUNCTIONS OF THE JOB, WITH OR WITHOUT REASONABLE ACCOMMODATION FOR WHICH YOU ARE
APPLYING?
 NO  YES
___________________________________________________________________________________________________________

CRIMINAL/LICENSING AND CERTIFICATION MATTERS
Have you ever been convicted of (or pleaded guilty or nolo contendere to) a crime? (Do not identify marijuana-related misdemeanor convictions occurring more than two years ago or convictions for which the criminal records have been expunged, sealed, or eradicated by the court, or misdemeanor convictions for which any probation has been completed and the case dismissed by the court).  NO  YES
NO. OF TIMES________
Did the conviction(s) (or guilty or nolo contendere pleas) result in imprisonment?
 NO  YES
NO. OF TIMES________
Explain each conviction (and guilty or nolo contendere plea) fully. (A conviction or guilty or nolo contendere plea will not necessarily disqualify an applicant)______________________________________________________________________________________
___________________________________________________________________________________________________________
Have you ever had a certification and/or license suspended, revoked or placed on probation?
 NO  YES
EXPLAIN__________________________________________
Are you currently charged with an unresolved criminal charge (a charge which has not yet resulted in a plea, trial, or a dropping of the charge, or for which you are out on bail or on your own recognizance pending trial)?  NO  YES
If yes, please fully explain the charge (a charge will not necessarily disqualify an applicant)_________________________________

REFERENCES
GIVE THE NAMES OF THREE PERSONS NOT RELATED TO YOU WHOM YOU HAVE KNOWN FOR AT LEAST ONE YEAR
NAME
ADDRESS
PHONE
YEARS KNOWN
1. _______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
2. ______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
3. ______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

AUTHORIZATION
PLEASE READ CAREFULLY AND INITIAL EACH PARAGRAPH BEFORE SIGNING
“I declare under penalty of perjury that the facts contained in this application or any resume or other documentation submitted is true and complete to the best of my knowledge. I understand that any false information or significant omissions will disqualify me from further consideration for employment and will be justification for my dismissal from employment, if discovered at a later date.”

__________INITIALS
“I agree to immediately notify the company if I should be convicted of any crime while my job application is pending or during my period of employment, if hired.”

__________INITIALS

“I authorize the investigation of all statements contained in this application (and accompanying resume, if any) and further authorize any person, school, current employer (except as expressly noted), past employer(s), consumer reporting agency and organizations, whether or not named in this application (and accompanying resume if any) to provide the company with records information and opinion that may be useful in making a hiring decision. I release all such informants and the company from all liability for any decision, claim or damage that may result from furnishing and/or relying on such information and opinion (which is truthful or made in good faith) to you.”

__________INITIALS

“I give permission for a pre-employment drug/alcohol screening exam and, if the company makes a conditional job offer, I give permission for a complete employment physical examination. I also consent to the appropriate release of any and all medical information, as may be deemed necessary.” __________INITIALS

“I understand that if hired, and during my employment, I shall always give preference to this company’s business. I further agree not to use or disclose company trade secrets or confidential or proprietary information to anyone outside the company or anyone within the company who is not authorized to have the information. I will not engage in other activities that create a conflict of interest with my position with the company unless given permission in writing by the company.”

__________INITIALS

AGREEMENT FOR AT-WILL EMPLOYMENT
“If I become employed, in consideration of my employment, I agree that my employment will be at-will, and may be terminated with or without cause, and with or without notice, at any time at the option of myself or the company. Only the Chief Executive Officer of the company has the authority to enter into an employment agreement for a specified period of time or for termination only for cause, and any such agreement must be in writing. I understand and acknowledge that this constitutes the entire agreement between me and the company regarding the term of my employment and supersedes any other oral or written agreement.”

__________INITIALS

COMPLIANCE WITH RULES
“If I become employed, in consideration of my employment, I agree to comply with the rules, regulations, policies and procedures of the company.”

__________INITIALS

PRE-EMPLOYMENT DOCUMENTS
“If offered employment, I understand that I will be required to review, complete, and execute various employment documents (including, but not limited to; this application, employee handbook and employee handbook receipt form, at-will employment and confidentiality agreement, [as applicable], and agree that the process of my being hired will not be complete until all employment documents have been signed.”

__________INITIALS

APPLICANT SIGNATURE______________________________________________ DATE____________________________