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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:
Social Security Number:
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: