Job Application

Applicant Name

First & last name

Are you at least 18 years old? *

Phone Number *

Email *

Mailing Address *

Include city, state, and ZIP code

Current Open Position(s) for which you are applying: *

Type of Position *

Shift *

Salary Requirement

Are you willing to travel?

Are you willing to relocate?

If overtime is required periodically, does this pose a problem for you?

Date Available for Work:

Are you legally authorized to work in the US?

Are you related to another facility employee?

If yes, please provide name:

Have you ever worked at this facility or a facility associated with Savoy Medical Center?

If yes, what facility?

Are you currently excluded, suspended, debarred, or otherwise ineligible to participate in federal health care programs, or have you been convicted of a criminal offense related to the provision of health care items or services but not yet excluded, debarred, or otherwise declared ineligible? *

Educational History

Include high school, college, graduate school, and other
Include name of school, city, state, degree, and date graduated

List any professional licenses, registration, or certification you possess

Include type of license, number, and expiration date
Include driver’s license, if applicable

Clerical or other skills applicable to the position for which you are applying:

Examples: typing, PBX, software, business machines and/or equipment you can operate

Employment History *

Current or most recent employment

Dates of Employment *

Phone Number of Employer

Immediate Supervisor

First

Last

May we contact your supervisor?

Address

Include city, state, and ZIP code

Salary

Job Title

Nature of Duties

Reason for leaving position

Employment History – 1st Previous

Previous employment

Dates of Employment

Phone Number of Employer

Immediate Supervisor

First

Last

May we contact your supervisor?

Address

Include city, state, and ZIP code

Salary

Job Title

Nature of Duties

Reason for leaving position

Other Employment

Please list other employers & dates of employment, if applicable

Professional Reference #1

First & last name of professional reference (other than relatives)

Position / Title

Address

Contact for Reference

Include work and/or cell number

Number of Years Known

Professional Reference #2

First & last name of professional reference (other than relatives)

Position / Title

Address

Contact for Reference

Include work and/or cell number

Number of Years Known

By checking the box below, I certify that the information in this application is true and complete for all practical purposes. It may be verified by the facility or any affiliate. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the facility or its affiliates are relieved of all commitment, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse. *

I have read and understand this condition of employment.

I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable. If such an investigative report is made, I understand that I will receive notice that such a report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation. *

I have read and understand this condition of employment.

I understand and agree that any employee handbook which I may receive will not constitute an employment contract, but will be merely a gratuitous statement of facility policies. *

I have read and understand this condition of employment.

I understand that the facility reserves the right to require its employees to submit to blood tests or urinalysis for alcohol or drug screens, or to allow inspection of bags (including purses or briefcases) or parcels brought into or taken out of the facility. I understand that refusal to submit to a urinalysis, blood test, or search, when requested to do so, may result in termination of my employment. *

I have read and understand this condition of employment.

Compliance with this facility's Substance Abuse Policy is a condition of employment. This facility requires that every new employee be free of alcohol or drug abuse. Each offer of employment is contingent upon successfully completing an urinalysis test/screen for alcohol and drugs in accordance with facility policy. Continued employment is also contingent upon compliance with the facility's Substance Abuse Policy. *

I have read and understand this condition of employment.

I agree to immediately disclose to the Company any debarment, suspension, exclusion, or other event that makes me ineligible to participate in any Federal Health care program, or receive a government contract. *

I have read and understand this condition of employment.

I understand and agree that if I am offered employment by the facility, my employment will be for no definite term and that the facility may terminate the employment relationship for cause. Cause is defined as a reason for disciplinary action that is not arbitrary, capricious, or illegal, that is based on facts that the employer reasonable believes to be true. Some examples of cause include but are not limited to: (1) dissatisfaction with an employee for such reasons as lack of capacity or diligence, failure to conform to usual standards of conduct, or other culpable or inappropriate behavior, or (2) economic needs subject to the reasonable judgement of the employer. *

I have read and understand this condition of employment.

Release: I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my licensure status and my licensure history. *

I have read and understand this condition of employment.