Hwi application 1

Employment Application Rev. 6/30/08

Employment Application

Position Applied for: Nursing Assistant Environmental Services Worker Nutrition Services Worker Applicant Information

Full Name: Date: Last First M.I.

Address: Street Address Apartment/Unit #

City State ZIP Code

Phone: E-mail Address:

Date Available: Social Security No: - -

Desired Shift: 1st 2nd 3rd

Desired Status: F/T P/T or Resource

Hospital Location Desired: Charles F. Kettering Memorial Hospital Kettering Medical Center-Sycamore Grandview Medical Center Southview Hospital Kettering Hospital Youth Svcs.

How did you hear about the HWI Program? KMCN Employee Job Bank KMCN Website Other:

Education

High School: Address:

Did you graduate? YES

NO

If not, do you have a GED?

YES

NO

College: Address:


NO

Degree:

Other: Address:


NO

Degree:

Employment References

Please list three employment references (Preferably from an immediate supervisor or manager)

Full Name: Title:

Company: Phone:

( ) -

Address:

Full Name: Title:

Company: Phone:

( ) -

Address:

Full Name: Title:

Company: Phone: ( ) -

Address:

Healthcare Workforce Initiative 1111 South Edwin C. Moses Blvd.

P.O. Box 972 Dayton, OH 45422


Previous Employment Account for ALL times for the past 10 years, including periods of unemployment. If you need more room, use a separate piece of paper. A RESUME is both welcomed and urged in addition to completion of this application.


Address: Supervisor:

Job Title: Starting Salary:

$ Ending Salary:

$

Responsibilities:

From: To:

Reason for Leaving:

May we contact your previous supervisor for a reference? YES

NO



Job Title: Starting Salary: $ Ending Salary: $

Responsibilities:

From: To: Reason for

Leaving:


NO




Responsibilities:


Leaving:


NO

Are you authorized to work in the U.S.? YES

NO

Have you ever worked for the Kettering Medical Center Network?

YES

NO

If yes, when and at which facility?

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Yes No If Yes, describe all of these actions, including the nature of the criminal offense(s), the location(s), the dates and their disposition. Conviction of a crime is not an automatic bar for consideration for employment. Falsification of information will result in rejection of application. (If necessary, use a separate piece of paper): If yes, explain:


Additional Previous Employment




Responsibilities:


Leaving:


NO




Responsibilities:


Leaving:


NO




Responsibilities:


Leaving:


NO


Disclaimer and Signature

***********************************STOP HERE—PRINT, SIGN, AND DATE APPLICATION ********************************** I understand that my employment thereof is contingent upon positive results of a successful pre-placement physical, including drug screen analysis, criminal background checks and possible fingerprinting. The result of such analysis may be grounds for disqualifying me or terminating my employment. I authorize schools, references, my prior employers and physicians or other medical practitioners to provide my record, reason for leaving, and other information they may have concerning me to Montgomery County Department of Job & Family Services and Kettering Medical Center Network and I release all parties from any and all liability to claims for damage whatsoever that may result there from.

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature: Date: