Application for Employment

"*" indicates required fields

In considering your application for employment, the facility may conduct a detailed and thorough investigation which may include, but is not limited to, a criminal record check. Interviews or inquires of prior employers, co‐workers, acquaintances, relatives or friends.
Name:*
Address:*
Position(s) you are applying for:*
Are you a citizen of the United States?
If no, are you authorized to work in the U.S.?
Have you ever worked for this company?
Have you ever been convicted of, or plead guilty to a crime other than misdemeanor traffic violation?
Have you ever been involved in the substantiated abuse or neglect of children or adults under the laws of this or any other state in the United States?
Have you been sanctioned, cited, reported, or excluded from participation in Medicare, Medicaid, or any other healthcare related law or regulation?
If your answer is "yes" to any of the above, you will not be automatically disqualified from employment consideration, except as required by state or federal law.

Education

Start Date:
End Date:
Did you graduate?
Start Date:
End Date:
Start Date:
End Date:

Professional Licenses & Certifications

License or Registration:
MM slash DD slash YYYY
Has your License or Certification ever been suspended, revoked or on probation?
License or Registration:
MM slash DD slash YYYY
Has your License or Certification ever been suspended, revoked or on probation?

Previous Employment

Employment Start Date:
Employment End Date:
May we contact your previous supervisor for a reference?
Employment Start Date:
Employment End Date:
May we contact your previous supervisor for a reference?
Employment Start Date:
Employment End Date:
May we contact your previous supervisor for a reference?

References

Name:
Address:
Name:
Address:
Name:
Address:

Language

Disclaimer

I hereby affirm the information provided on this (and accompanying resume, if any) is true and complete. I understand that any false or misleading representations or omissions made on the application or during the hiring process may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date. I understand that employment may be conditioned upon successfully passing a medical examination and that I may be required to satisfactorily complete a drug screening as a condition of employment. I hereby authorize persons, schools, my current employer (if applicable) and previous employers and other organizations to provide this facility and its affiliates with any requested information regarding my application or suitability for employment, and I completely release all such persons or entities from any and all liability related to the providing or use of such information. I understand that my employment is at‐will which means that I may terminate the employment relationship at any time and for any reason with or without notice, and that the facility has the same right. I understand that no one has the authority to enter into any agreement contrary to the preceding sentence, except for a written agreement signed by an administrative of this facility and notarized.*
Max. file size: 50 MB.
Max. file size: 50 MB.
How did you hear about career opportunities at Kearny County Hospital?