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TRI-HOSPITAL EMeRGENCY MEDICAL SERVICE
APPLICATION FOR EMPLOYMENT
Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, height, weight, disability or other factor prohibited by law.

 

Position(s) Applied For
Referral Source

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 Friend Relative Walk-ln
  Employment Agency Other
Name
  Last name First name Middle name
Email
Address Number/Street City State
Zip Code
Telephone - Social Security Number
lf employed and you are under 18, can you furnish a work permit?
Yes No
Have you filed an application here before?
Yes No If yes, give date
Have you ever been employed here before?
Yes No If yes, give date
Are you employed now?
Yes No May we contact your present employer ? Yes No
Are you prevented from lawfully becoming employed in this country because of Visa or lmmigration Status? Yes No
(Proof of citizenship or immigration status will be required upon employment)
On what date would you be available to work?
Are you available to work?
Full-Time Part-Time Shift Work Temporary
Are you on a layoff and subject to recall?
Yes No  
Can you travel if a job requires it?
Yes No  
Are you barred or otherwise precluded from providing services under Medicare or Medicaid Programs?
Yes No  
lf yes, please explain.
Have you been convicted of or pled " No Contest," "No Contendre" or "Guilty" to a felony or misdemeanor at any time?
Yes No

Are you currently awaiting trial or other dispositions of a felony charge in connection with which you are currently out on bail or on your own recognizance?
Yes No
If yes to either questions, please explain.
NOTE: A conviction record will not necessarily be a bar to employment, and factors such as the applicant's age at the time of the offense, the age of the offense, and the nature and seriousness of the violation will be taken into account.

EdUCATION
  Elementary High College/University Graduate/ Professional
School Name
Years Completed/
Degree
Diploma/Degree
Describe Course
of Study
 
Honors Received :
State any additional information you feel may be helpful to us in considering your application.

EMPLOYMENT EXPERIENCE
List all jobs in order starting with your present or last job. You may exclude organization names which indicate race, color, religion, gender, national origin, disability or other protected status.  Describe any other job related training or experience you have received in the Military Services or elsewhere.
Employer-1 Telephone Dates Employed Work Performed
From To
Address:
Job Title: Hourly Rate/Salary  
Supervisor: Starting Final  
Reason for Leaving
Employer-2 Telephone Dates Employed Work Performed
From To
Address:
Job Title: Hourly Rate/Salary  
Supervisor: Starting Final  
Reason for Leaving
Employer-3 Telephone Dates Employed Work Performed
From To
Address:
Job Title: Hourly Rate/Salary  
Supervisor: Starting Final  
Reason for Leaving
Employer-4 Telephone Dates Employed Work Performed
From To
Address:
Job Title: Hourly Rate/Salary  
Supervisor: Starting Final  
Reason for Leaving
Employer-5 Telephone Dates Employed Work Performed
From To
Address:
Job Title: Hourly Rate/Salary  
Supervisor: Starting Final  
Reason for Leaving
 

SPECIAL SKILLS AND QUALIFICATIONS
Summarize special skills and qualifications acquired from employment or other experience.
Are you physically and mentally able to perform the essential functions of the position for which you are applying, either with or without reasonable accommodation? Yes No
lf accomodation is required, please explain:
 

1. In consideration of any employment of me by your Company, I agree that my employment is at the will of the Company, which means that the Company has the right to discharge me or lay me off at any time, with or without cause, and with or without notice. lt is expressly agreed and understood that this is the entire agreement between the Company and myself on the subject of discharge termination and/or layoff, and that this agreement may be changed only by an agreement in writing signed by the President of the Company and addressed specifically to me.

2. I further recognize that if employed by the Company, I agree in partial consideration for my employment, that I shall not commence any action or other legal proceeding relating to my employment or the termination thereof more than six months after the claim arises or within the applicable statutory limitations period(s) provided by law, whichever occurs first.

3. I understand that any offer of employment made to me by the Company is contingent upon a favorable health evaluation which may include a physical examination by a doctor elected by the Company. I hereby agree to complete a health evaluation form.

4. I hereby authorize an investigation of my past employment activities and statements contained in this application and specifically authorize the Company to consult with all third parties with whom or which I have been associated concerning my qualifications, or with any third parties who may have information bearing thereon, and to receive and utilize any information which may be material to my qualifications. I hereby release all third parties who provide information to the Company with or without notice to me, from any and all liability for the transmittal of any information bearing on my qualifications. In connection with any such request, I further authorize and release the Company from all liability for forwarding to any other entity to which I may apply for employment, any information concerning me and/or my qualifications as the Company has at the time of my applicalion for employment or hereafter acquires. I further release from all liability any and all third parties for any statements made or any action taken in connection with this application or any other applications made simultaneously herewith, or in connection with any other form of review of my qualifications. I hereby waive on behalf of the Company and any and all third parties any and all notice(s) I would otherwise be entitled to under Public Act 397 or 1978.

5. I will hold in the strictest confidence and will not disclose directly or indirectly to any unauthorized persons, without the Company's prior written permission, at any time during or subsequent to my employment, any knowledge not already available to the public, respecting the inventions or respecting designs, methods, systems, improvements, trade secrets, manufacturing techniques and processes, sales promotions and ideas, customer lists or other confidential matters of the Company.

6. I understand that if I have a disability I must timely tell you in writing of my need for accommodation after I know or reasonably should know that an accommodation is needed. I further understand that failure to do so will prevent me from alleging a violation of the accommodation requirements otherwise imposed by law.

7. I hereby certify that I am not barred or otherwise precluded from providing services under either the Medicare Program or the Medicaid Program.

8. I certify that all information submitted by me in this application is true and correct and understand that if any such information is found to be false or otherwise incorrect, it may result in disciplinary action against me up to and including discharge from employment.

9. I understand this application will be considered current for 90 days and that a new application must be completed for further consideration after 90 days.

10. In the event that one or more provisions of this application are declared void, the balance of the provisions shall remain in force.
I hereby acknowledge that I have read the above statements and understand the same.
Signature Date
   
 
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