Application for Employment

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.

Position(s) Applied For

Date of Application

How did you Learn about Us?

Advertising	Friend	Walk-In
Employment Agency	Relative	Other

Date Updated

Last Name

First Name

Middle Name

Address

City

State

Zip

Telephone Number(s)

Social Security Number

If you are under 18 years of age, can you provide required proof of eligibility to work?	Yes No
Have you ever filed an application with us before? If yes, give date	Yes No
Have you ever been employed with us before? If yes, give date	Yes No
Are you currently employed?	Yes No
May we contact your present employer?	Yes No
Are you prevented from lawfully becoming employed in the country because of Visa or immigration status? Proof of citizenship or immigration status will be required upon employment.	Yes No
On what date would you be available for work?
Are you available to work: Full Time Part Time Shift Work Temporary
Are you currently on "lay-off" status and subject to recall?	Yes No
Can you travel if a job requires it?	Yes No
Have you been convicted of a felony within the last 7 years? Conviction will not necessarily disqualify an applicant from employment.	Yes No
If yes, please explain:

Education
Indicate any foreign languages you can speak, read, and/or write.

	Fluent	Well	Fair
Speak
Read
Write

	Name/Address of School	Course of Study	Years Completed	Diploma/Degree
Elementary School
High School
Undergraduate College			Fromto
Graduate Professional			Fromto
Other(Specify)			Fromto

Describe any specialized training, apprenticeship, skills, extra-curricular activities, or special job-related skills and qualifications acquired from employment or other experiences.

Specialized Skills
Please check skills/equipment operated.
Fax PC Calculator Typewriter

Computer Software (Please List):

Other:

Employment Experience

Start with your present or last job, include any job-related military service assignemtns and volunteer activities. You may exclude organizations which indicated race, color, religion, gender, national origin, disabilities or other protected status.

1. Employer	Dates Employed From to	Work Performed
Address
Phone Number	Hourly Rate/Salary Staring: Final:
Job Title Supervisor
Reason for Leaving

2. Employer	Dates Employed From to	Work Performed
Address
Phone Number	Hourly Rate/Salary Staring: Final:
Job Title Supervisor
Reason for Leaving

3. Employer	Dates Employed From to	Work Performed
Address
Phone Number	Hourly Rate/Salary Staring: Final:
Job Title Supervisor
Reason for Leaving

4. Employer	Dates Employed From to	Work Performed
Address
Phone Number	Hourly Rate/Salary Staring: Final:
Job Title Supervisor
Reason for Leaving

5. Employer	Dates Employed From to	Work Performed
Address
Phone Number	Hourly Rate/Salary Staring: Final:
Job Title Supervisor
Reason for Leaving

References

Name

Address

Phone

Name

Address

Phone

Name

Address

Phone

If your references know you by another name, please list that name also, (i.e. your maiden name.):

Notice to Applicants
Screening tests for alcohol and illegal drug use are required before hiring and may be required during your employment here.

Applicant's Statement

I certify that answers given herein are true and complete to my knowledge.

I hereby authorize Brookville Hospital, or any investigator or duly accredited representative of Brookville Hospital bearing this release, to obtain any information from schools, residential management agents, employers, criminal justice agencies, or individuals relating to my activities. This information may include, but is not limited to academic, residential, achievement, performance, attendance, personal history, disciplinary, arrest, and conviction records. I hereby direct you to release such information upon request of the bearer.

I hereby release any individual, including record custodians, from any and all liability for damages of whatever kind or nature which may at any time result to me on account of compliance, or any attempts to comply, with authorization.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

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