APPLICATION FOR EMPLOYMENT*Physical TherapistPhysical Therapy AssistantOccupational TherapistCertified Occupational Therapy AssistantSurgical TechnologistAdministrative AssistantPatient Financial Services ClerkClinical AssistantMedical Office ClerkRegistered Nurse-Operating Room and Specialty ClinicParamedicRN-ERRN -Med/SurgGeneral ApplicationDate of Application MM slash DD slash YYYY I am interested in* Full-Time (32-40hrs/wk) Part-Time (16-31hrs/wk) Casual/PRN Pool (no benefits) Temporary I would be available to work* Day Evening Night First Name* Middle Name Last Name* Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address* Day Phone number*Evening Phone numberHave you worked under another name?* Yes No If yes, list name (s) Have you worked for Community Medical Center previously?* Yes No If yes, in what capacity What date did you leave employment? MM slash DD slash YYYY If hired, can you provide proof of your eligibility to be employed in the United States?* Yes No Are you 18 years of age, or older?* Yes No Have you ever been convicted of ANY crime? (conviction will not necessarily disqualify applicant from employment)* Yes No Disclose ALL misdemeanors and felonies (including Driving Under the Influence (DUI), Minor in Possession (MIP) but you may exclude minor traffic violations) NOTE: Omitting information or failure to disclose may disqualify you from consideration.If yes, please explainEDUCATION AND TRAININGName and Location of School Degree/Certificate Earned Graduation Date MM slash DD slash YYYY Major and Minor Fields of Study Dates Attended MM slash DD slash YYYY PROFESSIONAL LICENSES AND/OR CERTIFICATIONSProfession State Issued License Number Has your professional license (in any state) ever been on probation, suspended, revoked, or limited in any way? Yes No If yes, give reason Please list any relevant certifications Provide expiration dates, i.e. BLS, ACLS, CCRN: MM slash DD slash YYYY EMPLOYMENT RECORD List your present or most recent employer FIRST. Include U.S. Armed Forces experience.Account for ALL the time during the past 7 years including period of unemployment. Include any unpaid work experience. (Attach additional pages as needed.) Omit reasons for leaving if for reasons of health or disability. Resumes are acceptable but may NOT be substituted for the following informationEmployer Full Time Part Time Employed From MM slash DD slash YYYY Employed To MM slash DD slash YYYY Job Title Primary Duties/ResponsibilitiesManager Phone # Reason for leavingSalary Start Salary End May we contact employer? Yes No If no, why: Employer Full Time Part Time Employed From MM slash DD slash YYYY Employed To MM slash DD slash YYYY Job Title Primary Duties/ResponsibilitiesManager Phone # Reason for leavingSalary Start Salary End May we contact employer? Yes No If no, why: Employer Full Time Part Time Employed From MM slash DD slash YYYY Employed To MM slash DD slash YYYY Job Title Primary Duties/ResponsibilitiesManager Phone # Reason for leavingSalary Start Salary End May we contact employer? Yes No If no, why: Employer Full Time Part Time Employed From MM slash DD slash YYYY Employed To MM slash DD slash YYYY Job Title Primary Duties/ResponsibilitiesManager Phone # Reason for leavingSalary Start Salary End May we contact employer? Yes No If no, why: Employer Full Time Part Time Employed From MM slash DD slash YYYY Employed To MM slash DD slash YYYY If no, why: Job Title Primary Duties/ResponsibilitiesManager Phone # Reason for leavingSalary Start Salary End May we contact employer? Yes No If no, why: Employer Full Time Part Time Employed From MM slash DD slash YYYY Employed To MM slash DD slash YYYY Job Title Primary Duties/ResponsibilitiesManager Phone # Reason for leavingSalary Start Salary End May we contact employer? Yes No If no, why: Please list any skills and abilities you wish to be considered. Include skills with equipment or machines you operate, special computer knowledge, laboratory techniques, foreign languages etcPROFESSIONAL REFERENCES Please provide information for three work related references that we may contact. Please do not include relatives.Name, Job Title* Telephone # in which they can be reached at*Relationship (Co-Worker/Supervisor) Name, Job Title* Telephone # in which they can be reached at*Relationship (Co-Worker/Supervisor) Name, Job Title* Telephone # in which they can be reached at*Relationship (Co-Worker/Supervisor) HOW WERE YOU REFERRED TO COMMUNITY MEDICAL CENTER Employee referral Walk – In School Workforce Development CMC Website Newspaper Other Name of employee EMPLOYMENT AGREEMENT Please read the following carefully before signing this application form. Community Medical Center, Inc. reserves the right to reject any application which has not been fully completed. I certify the information contained in this application for employment is true to the best of my knowledge and belief. I understand that any omission of facts or misrepresentation is cause for denial of employment and/or dismissal (if hired) regardless of when discovered. I grant permission for the authorities of Community Medical Center to investigate my work references and release them and any former employer from any and all liability resulting from such investigation. Upon my termination, I authorize the release of reference information on my work. I agree to submit to a post-offer physical, including drug and/or alcohol screening and recognize employment is contingent upon successfully meeting physical requirements. I further agree that if I’ve been convicted of a crime, the authorities of Community Medical Center may obtain details of my conviction to determine its relationship to the position I’m applying for as a condition of my employment. In consideration of my employment, I agree to conform to the rules and regulations of Community Medical Center. My employment may be terminated, with or without cause, at any time, at the option of Community Medical Center or myself. I understand that Community Medical Center operates 24 hours a day, seven days a week, and that weekend work, holidays, or changes of shift may be required during my employment. Community Medical Center is tabacco-free. Tobacco use is prohibited on all CMC property. In accordance with the Drug-Free Workplace Act of 1988it is the policy of Community Medical Center to provide a safe environment for patients, employees and visitors. The illegal manufacture, possession, distribution or use of controlled substances by employees in the workplace is prohibited. In accordance with Federal law and U.S. Department of Agriculture policy, CMC is prohibited from discriminating on the basis of race, color, national origin, sex, religion, age, disability or marital or family status. We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, disability, marital or veteran status, or any other legally protected status. Printed Name eSignature Date MM slash DD slash YYYY Community Medical Center Standards of Behavior CMC employees believe that through teamwork, we can achieve better results than we could produce as individuals. We are truly committed to excellence, therefore we must help each other adhere to these Standards of Behavior as we continue to grow and learn in order to provide outcomes that exceed our customer’s expectations. Choose a sincerely good attitude by smiling, being friendly and courteous and treat everyone as if they are the most important person in our facility. Acknowledge everyone as you pass them in the hallway. Speak highly of our patients, coworkers, practitioners, volunteers, other departments and CMC. Refrain from making excuses or placing blame. Take personal ownership and welcome feedback/suggestions. Always talk with your co-workers in a thoughtful and respectful manner. Communicate directly with the person or people involved when addressing concerns. Sincerely apologize and seek remedies when expectations are not met. Escort anyone who is lost or find someone who can assist. Help to maintain a quiet, calming and professional environment, keeping noise level in and around patient care areas and hallways to a minimum. Maintain and respect patient privacy and modesty. Keep our environment clean and free of clutter, picking up trash in and around the campus. Inform patients and family members of wait times and provide timely updates. Refrain from negative gossip and using negative phrases, i.e. (We’re short staffed, It’s above my pay grade, I’m too busy) and understand that rudeness and offensive language are never acceptable. Refrain from unnecessary discussions about personal and work related issues in the presence of customers. Respect each other’s time by arriving on time for shifts, meetings and appointments. Accept responsibility for your role to regularly attend required meetings and read hospital communications. Show initiative beyond your assigned task and look for ways to meet requests in a positive way. Respond to all communication requests in a timely manner. Take pride in my appearance, adhering to the professional appearance policy and wearing my badge at all times. Welcome and mentor new employees. Hold each other accountable in a respectful manner for meeting our standards of behavior. I have read and understand the Community Medical Center Standards of Behavior. I recognize that every job is a self portrait of the person who does it. With this in mind, I pledge to practice these standards daily and to make these standards of performance my standards as a team member of Community Medical Center.Printed Name eSignature Date MM slash DD slash YYYY UntitledFirst ChoiceSecond ChoiceThird ChoiceUntitledFirst ChoiceSecond ChoiceThird ChoiceSection Break Δ
