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    Position Applied For:

      OR Fill The Below Form

      Date:

      APPLICATION FOR EMPLOYMENT
      Please Answer All Questions. Resumes Are Not A Substitute For A Completed Application.

      I UNDERSTAND THAT NEITHER THIS APPLICATION NOR ANY COMMUNICATION BY A MANAGEMENT REPRESENTATIVE
      IN INTENDED TO CREATE A CONTRACT OF EMPLOYMENT, OFFER, OR PROMISE OF EMPLOYMENT. I ACKNOWLEDGE
      THAT IF HIRED BY THE COMPANY, EMPLOYMENT IS ON AN AT-WILL BASIS. THIS MEANS THE COMPANY IS FREE TO
      TERMINATE MY EMPLOYMENT AT ANY TIME, WITH OR WITHOUT CAUSE OR ADVANCE NOTICE, IN ACCORDANCE WITH
      STATE LAW, AND ACCEPTANCE OF EMPLOYMENT IS NOT A CONTRACT OF EMPLOYMENT FOR ANY SPECIFIED TIME.
      SIMILARLY, I AM FREE TO TERMINATE MY EMPLOYMENT WITH THE COMPANY AT ANY TIME FOR ANY REASON. THIS
      AT-WILL PROVISION MAY BE MODIFIED OR WAIVED ONLY IN A WRITTEN AGREEMENT SIGNED BY AN AUTHORIZED
      REPRESENTATIVE OF THE COMPANY AND ME. I AGREE TO CONFORM TO THE RULES AND REGULATIONS OF THE
      COMPANY, AND I UNDERSTAND THAT THE COMPANY HAS COMPLETE DISCRETION TO MODIFY SUCH RULES AND
      REGULATIONS AT ANY TIME, EXCEPT THAT IT WILL NOT MODIFY ITS POLICY OF EMPLOYMENT AT-WILL.
      We are an equal opportunity employer. Applicants are considered for positions without regard to race, religion, color, sex, sexual orientation, gender identity, national origin, age, veteran or disability status, or any other status protected by law.

      Position Applied For:
      Name
      Telephone Number
      Present address (Street, Apt. or Unit No.)
      City / State / Zip
      Email Address
      Desired Salary
      Are you able at the time of employment to submit verification of your legal right to work in the U.S.? (Verification and completion of Form I-9 must be submitted no later than three business days after date hire.)
      YesNo
      If under the age of 18, can you produce the necessary work certificate at the time of employment?
      YesNo
      Type of employment desired? Full TimePart Time (Specify Hours)
      Shift desired? DaysEveningsNights (Specify Hours)
      Are you willing to work overtime? YesNo Date on which you can start
      Have you ever applied to this company before? YesNo If yes, when did you apply?
      How did you hear about the hospital (who referred you)?
      Within the past (10) years, have you been convicted of a felony, misdemeanor, or deferred adjudication? (Criminal convictions/deferred adjudication will not automatically disqualify you from a particular job. The Hospital will consider the nature of the crime, its seriousness, whether the conviction(s) substantially relates to the position’s function and qualifications)
      YesNo
      If yes, please explain so that individual circumstances can be considered
      Have you ever initiated an act of violence in the workplace? YesNo
      If yes, please explain so that individual circumstances can be considered. (A yes answer will not necessarily disqualify you from employment.)
      Do you currently hold a current American Heart Association Healthcare Provider Basic Life Support (CPR) Card? YesNo
      List special technical skills or certifications that you feel qualify you for the job for which you are applying (i.e., ACLS, PALS, TNCC, ENPC, CCRN, computer programming/language, software, equipment operation, special tools or machines, etc.):
      Education School Name and Location Course of study Graduate? # of years completed Degree/Major
      High School
      College
      Bus./Tech./Trade or Post College
      Honors Received
      WORK EXPERIENCE
      Start with your present or last place of employment. You may include any verifiable work performed on a volunteer basis, internships, or military service.
      Employer
      Name
      Address
      Type of Business
      Phone
      Dates Employed From

      To

      Job Title
      Supervisors Name
      May we contact?YesNo
      Reason for Leaving
      Wages Start
      Final
      Explain any gap in employment
      Duties and areas worked
      .
      Employer
      Name
      Address
      Type of Business
      Phone
      Dates Employed From

      To

      Job Title
      Supervisors Name
      May we contact? YesNo
      Reason for Leaving
      Wages Start
      Final
      Explain any gap in employment
      Duties and areas worked
      REFERENCES
      Please list the names of additional work-related references we may call. Individuals with no prior work experience may list school or volunteer related references.
      NAME POSITION COMPANY WORK RELATIONSHIP TELEPHONE #
      APPLICANT CERTIFICATION

      I understand and agree that if driving is a requirement of the job for which I am applying, my employment and/or continued employment is contingent on possessing a valid drivers license and automobile liability insurance in an amount equal to the minimum required by the state where I reside.
      I understand that The Hospital at Westlake Medical Center has, or may establish, a drug-free workplace or drug and/or alcohol testing program consistent with applicable federal, state, and local law. If The Hospital at Westlake Medical Center has such a program and I am offered a conditional offer of employment, I understand that if preemployment (post-offer) drug and/or alcohol test is positive, the employment offer may be withdrawn. I agree to work under the conditions requiring a drug-free workplace, consistent with the federal, state, and local law. I also understand that all employees of the location, pursuant to The Hospital at Westlake Medical Center’s policy and federal, state, and local law, may be subject to urinalysis and/or blood screening or other medically recognized tests designed to detect the presence of alcohol or controlled drugs. If employed, I understand that the taking of alcohol and/or drug tests is a condition of continual employment and I agree to undergo alcohol and drug testing consistent with The Hospital at Westlake Medical Center’s policies and applicable federal, state, and local law.
      If employed by The Hospital at Westlake Medical Center, I understand and agree that The Hospital at Westlake Medical Center, to the extent permitted by federal, state, and local law, may exercise its right, without prior warning or notice, to conduct investigations of property (including, but not limited to, files, lockers, desks,
      vehicles, and computers) and, in certain circumstances, my personal property.
      I understand and agree that as a condition of employment and to the extent permitted by federal, state, and local law, I may be required to sign a confidentiality, non-compete, and/or conflict of interest statement.
      I certify that all the information on this application, my resume, or any supporting documents is complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any
      information may result in disqualification from consideration for employment or, if employed, disciplinary action, up to and including immediate dismissal.
      I authorize The Hospital at Westlake Medical Center or its agents to confirm all statements contained in this application and/or resume as it relates to the position I am seeking and to the extent permitted by federal, state, or local law. I agree to complete any requisite authorization forms for the background investigation.
      I authorize the consent to, without reservation, any party or agency contacted by this employer to furnish the
      above-mentioned information. I hereby release, discharge and hold harmless, to the extent permitted by federal, state, and local law, any party delivering information to The Hospital at Westlake Medical Center or its duly authorized representative pursuant to this authorization from any liability, claims, charges, or causes of action
      which I may have as a result of delivery or disclosure of the above requested information. I hereby release from liability The Hospital at Westlake Medical Center and its representative for seeking such information and all other persons, corporations, or organizations furnishing such information.
      I understand this company hires only individuals who are legally eligible to work in the United States

      Applicant Signature
      Date: