EMPLOYMENT APPLICATION
We consider applicants for all positions without regard to race, color, age, religion, creed, gender, disability, national origin, marital, veteran status and any other protected class. The use of this form does not obligate you or Halifax-Fish Community Health and its related entities.

Halifax-Fish Community Health is an Equal Opportunity Employer and a smoke free workplace.

Position and Affiliate:
1st Choice:                       2nd Choice:                       3rd Choice




Full Time    Part Time    Pool    Temporary    Summer Program 
High School Student Program 

Days    Evenings    Nights    Weekends

Date Available for Employment:   Salary Expected:

Applicant Information:
Last Name:  First Name: Middle Initial:
Social Security Number (Required)

Current Address Information:
Street and Number:  
City:   State: ZIP:

Telephone Numbers: (please include area code)
    Home: Example: 386-255-1212
    Work:
       Cell:

Are you at least 16 years of age?   Yes   No

Have you ever been known/worked by any other name(s)? No  Yes
If you answered Yes, Please List Name(s):

Have you ever worked for Halifax-Fish Community Health? No  Yes
If you answered Yes, Please List Affiliate:
List Employment Dates: Example: 12/99 - 06/01 (Month/Year)

Do you have relatives who work for HFCH? No  Yes
If you answered Yes, Please List Affiliate & Relative's name:

Have you applied with any HFCH affiliate within the past 90 days? No  Yes
If you answered Yes, Please List Affiliate:

How were you referred to HFCH?
Walk-In
Newspaper
Professional Journal
Hospital/Health Plan Reputation
Web Site
Recruitment Event
Personal Referral
Job Line
Employee Referral
Agency
Other

Only U.S. Citizens or individuals who have a legal right to work in the U.S. are eligible for employment. Can you, within 72 hours of employment, submit documentation verifying your legal right to work in the U.S. and your identity. Yes  No

Have you ever been convicted of a criminal offense, plea bargained, entered a plea of no contest or had adjudication withheld? Yes  No 
This information will not necessarily disqualify you from consideration for employment.

IF yes, list details: (include dates, state and court involved):

A criminal background check and drug screening will be completed on all employees hired by
Halifax-Fish Community Health.

Education

High School Name:   Location:
Year Completed: 9th   10th   11th   12th

Technical/Trade:    Location:
Years Completed: 1     2       3        4  
Degree/Certification:
Major(s): 
Minors(s):

College/University:    Location:
Years Completed: 1     2       3        4  
Degree/Certification:
Major(s): 
Minors(s):

Graduate/Professional:    Location:
Years Completed: 1     2       3        4  
Degree/Certification:
Major(s): 
Minors(s):

Professional Licenses, Certifications, Registrations

Do you currently hold a valid professional license/certificate for the position for which you are applying? Yes  No

List license/registration/certification numbers and issuing states in the box below...


If you are a new graduate and scheduled for state examination, list date:

Have you ever been denied a professional license, registration or certification: Yes  No
If you answered "yes", please explain in detail in the box below...


Is your license, registration or certification currently under investigation by any board or governing authority? Yes   No
If you answered "yes", please explain in detail in the box below...


If you are applying for a position that requires driving a motor vehicle,
list your drivers license number here:

Special Skills and qualifications

Have you had training or experience in any of the following areas:
Word Processing
Shorthand 
Transcription
PBX 
Typing - wpm:
Medical Terminology
ICD9/CPT Coding 
Computer Software - List Below...

List any other skills related to the position for which you are applying in the box below...


List additional trades, professional certificates, licenses or qualifications:

Employment History (Incomplete applications will not be accepted)
Please give complete employment history. Start with your present or last job; include any military assignment.

Employer:
Telephone: Example: 386-255-1212
Address:
City:  State:  ZIP:
Position Held:  Supervisor:
Dates:  From: to Example: 11/01 (Month/Year)
Wages: Starting: Ending: Example: $30,000/Yr or $20/Hr
Description of Work:
Reason for Leaving: 

_____________________________________________________________________


Employer:
Telephone: Example: 386-255-1212
Address:
City:  State:  ZIP:
Position Held:  Supervisor:
Dates:  From: to Example: 11/01 (Month/Year)
Wages: Starting: Ending: Example: $30,000/Yr or $20/Hr
Description of Work:
Reason for Leaving: 

_____________________________________________________________________

May we contact your current employer? Yes  No

Were you ever terminated or asked to resign? Yes  No
 If you answered Yes, Please Explain in box below:

List Periods of Unemployment (dates and reasons):

APPLICANT DATA RECORD
Completion of This Section of The Application is Completely Voluntary

Applicants are considered for all positions without regard to race, color, religion, creed, national origin, age, disability, marital or veteran status, or any other legally protected status.

As employers/governmental contractors, we comply with government regulations and affirmative action responsibilities.

This data will be maintained in a confidential file separate from the Employment Application.

Please Check One of the Following:  Male   Female

Please Check One of the Following:
American Indian/Alaskan Native
Asian/Pacific Islander
Black/African American
Hispanic
White

Veterans:
Please Check One if applicable;
Veteran of the Vietnam Era - an individual who served on active duty for a period of more than 180 days, any part of which occurred between August 5, 1964 and May 7, 1974, and was discharged or released therefrom with other than a dishonorable discharge; an individual who was discharged or released from active duty because of a service-connected disability if any part of such active duty was performed between August 5, 1964 and May 7, 1975; or an individual who was a reservist under an order to active duty, served on active duty between August 5, 1964 and May 7, 1975, and was discharged or released therefrom with other than a dishonorable discharge.

Other Eligible Veteran - an individual who served in a war, including veterans with active duty service between December 7, 1941 and April 28, 1952, and who served in a campaign or an expedition for which a campaign badge, a service medal, or an expeditionary medal was awarded.

NOTICE TO APPLICANTS: This employer complies with the Americans with Disabilities Act of 1990. During the interview process, you may be asked questions concerning your ability to perform job-related functions. If you are given a conditional offer of employment, you may be required to complete a post-job offer medical history questionnaire and/or undergo a medical examination. If required, all entering employees in the same job category will be subject to the same medical questionnaire and/or examination and all information will be kept confidential and in separate files.

APPLICANT'S STATEMENT

I certify that all statements made by me on this application are true, complete and correct to the best of my knowledge, and I hereby grant HFCH and its entities permission to verify such information and hereby release the Employer from any liability as a result of such contact. I understand that any false statements or omission of facts called for may be considered as sufficient cause for rejection of this application, or for dismissal if discovered during my employment. A criminal background check will be conducted for all new hires as well as Abuse Registry and Motor Vehicle, as required.

I understand that my employment with my employer is for no specific term and may be terminated by me or the employer with or without notice or cause at any time. I further understand that no oral promise, Employer policy, custom, business practice or other procedure (including the Employer's Personnel Handbook or any other personnel manuals) constitutes an employment contract or modification of the at-will employment relationship between me and the Employer. I also understand that no supervisor or other official of the Employer (except an Executive Officer, in writing) has the authority to enter into any agreement with me or to make any agreement contrary to the foregoing.

We conduct our business with the highest possible degree of safety and efficiency. Because of this, the Employer may require applicants for employment to undergo blood and/or urinalysis screening for drug use as part of our pre-placement physical examination. In addition, all employees of the Employer are subject to blood tests or urinalysis screening for drug or alcohol use at any time and immediately upon request of the Employer for cause.

ELECTRONIC SUBMISSION OF THIS FORM IS REGARDED AS ATTESTATION BY APPLICANT THAT THE FOREGOING INFORMATION IS COMPLETE AND TRUTHFUL. IF THIS APPLICATION LEADS TO AN INTERVIEW AND/OR MORE DETAILED CONSIDERATION FOR EMPLOYMENT, AN APPLICANT STATEMENT WILL NEED TO BE REVIEWED AND A SIGNATURE REQUIRED.


 
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