Position applied for: Date of application:
Referral Source:
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Employee
Relative
Government Employee Agency
Private Employment Agency
Other
Name of source (if applicable):
Upload your CV (optional):
GENERAL INFORMATION
Last Name: First Name: Middle Initial: SSN:
Street Address: City: State: Zip Code:
Home Phone: Cell Phone: Pager: Email:
If you are under 18 and it is required, can you furnish a work permit? YES NO
Are you legally eligible for employment in the United States? YES NO
Type of employment desired:
Date available to work: Desired Salary Range:
What days of the week are you available to work?
What hours of the day are you available to work?
Are you willing to work overtime? YES NO
Have you ever received sanctions or had limitations placed on any of your professional licenses or registrations?
YES NO
If yes, please explain:
Have you ever been convicted of a felony? YES NO
If yes, provide details including offense, date and jurisdiction:
Have you ever been terminated from or asked to resign a position? YES NO
EMPLOYMENT HISTORY
Provide the following information of your past and current employers, assignments or volunteer activities, starting with the most recent for the past 20 years. Please complete this section fully. Failure to provide all requested information may cause your application to not be considered.
(1)
Employer: Phone Number:
Employer Address:
Job Title: Immediate Supervisor and Title:
Reason for leaving:
Employed from: to
Beginning salary: Ending salary:
Job summary:
May we contact for reference? YES NO
(2)
Employer: Phone Number:
Employer Address:
Job Title: Immediate Supervisor and Title:
Reason for leaving:
Employed from: to
Beginning salary: Ending salary:
Job summary:
May we contact for reference? YES NO
(3)
Employer: Phone Number:
Employer Address:
Job Title: Immediate Supervisor and Title:
Reason for leaving:
Employed from: to
Beginning salary: Ending salary:
Job summary:
May we contact for reference? YES NO
(4)
Employer: Phone Number:
Employer Address:
Job Title: Immediate Supervisor and Title:
Reason for leaving:
Employed from: to
Beginning salary: Ending salary:
Job summary:
May we contact for reference? YES NO
(5)
Employer: Phone Number:
Employer Address:
Job Title: Immediate Supervisor and Title:
Reason for leaving:
Employed from: to
Beginning salary: Ending salary:
Job summary:
May we contact for reference? YES NO
(6)
Employer: Phone Number:
Employer Address:
Job Title: Immediate Supervisor and Title:
Reason for leaving:
Employed from: to
Beginning salary: Ending salary:
Job summary:
May we contact for reference? YES NO
(7)
Employer: Phone Number:
Employer Address:
Job Title: Immediate Supervisor and Title:
Reason for leaving:
Employed from: to
Beginning salary: Ending salary:
Job summary:
May we contact for reference? YES NO
(8)
Employer: Phone Number:
Employer Address:
Job Title: Immediate Supervisor and Title:
Reason for leaving:
Employed from: to
Beginning salary: Ending salary:
Job summary:
May we contact for reference? YES NO
EDUCATION AND TRAINING
Education Name of Institution
Highest
Grade/Year
Completed
Grade Average
Did you graduate?
Degree and Major
High School and/or GED
YES NO
Trade or Business School
YES NO
Trade or Business School
YES NO
College
YES NO
College
YES NO
Graduate School
YES NO
List any other education and training:
List both current and inactive professional licenses and registrations:
List any additional information you would like us to consider:
APPLICATION DISCLOSURE/RELEASE
Pursuant to the requirements of the Fair Credit Reporting Act, notice is given that a consumer report* may be made in connection with your Application for Employment.
If you are denied employment, either wholly or partly, because of information contained in a consumer report*, a disclosure will be made to you of the name and address of the consumer reporting agency making such report. You will also receive a copy of the report and a statement of your consumer rights.
*A consumer report may consist of employment records, educational verification, driving history, previous addresses, and other public records relative to criminal charges. A credit report will not be requested, unless it is deemed pertinent to the functions of the position for which you are applying.
APPLICANT CONSENT
By accepting below, you consent to the procurement of a consumer report* in connection with your application for employment and/or continued employment.
I understand that Renaissance Hospital of Dallas will verify all or part of the information I have given my prospective employer. I understand that this verification may include an inquiry into my credit history, motor vehicle driving record, criminal and civil records, prior employment (including contacting prior employer) education (degree, GPA, and attendance) as well as other pubic record information. I authorize the release of such information as may be necessary to verify the information I have provided.
I release and I agree to the above requirements: YES NO
Social Security Number: Date of Birth: (mm/dd/yyyy )
Last Name:
Applicants Other Last Names:
Applicants (printed) First Name:
Middle Name:
Driver’s License Number:
* for consumer report purposes only
Current Address
Address: Apt.#:
City: State: Zip:
List all cities, states and counties lived in for the last SEVEN YEARS.
complete and correct.
I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to cancel further consideration of this application or immediately discharge me from the employer’s services, whenever it is discovered.
I hereby authorize any investigator or duly accredited representative of the employer bearing this release to obtain any information from schools, residential management agents, employers, criminal justice agencies, or individuals, relating to my activities. This information may include, but is not limited to, academic, residential, achievement, performance, attendance, personal history, disciplinary, arrest, and conviction records. I hereby direct you to release such information upon request of the bearer. I understand that the information released is for official use by the employer and may be disclosed to such third parties as necessary in the fulfillment of official responsibilities.
I hereby release any individual, including record custodians, from any and all liability for damages of whatever kind or nature which may at any time result to me on account of compliance, or any attempts to comply, with this authorization.
I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant form consideration for employment on a basis prohibited by applicable local, state or federal law.
I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application.
I understand that in order to comply with the Drug Free Workplace Policy I will be asked to provide a urine specimen for testing to determine the presence of alcohol, drugs, or controlled substances in my system. I understand that I do not have to provide a specimen, however, that my refusal to do so will result in termination of my employment or my disqualification of employment at this time.
If I am hired, I understand that I must show evidence of being negative for Tuberculosis by either a skin test or chest x-ray before my first day of employment and annually thereafter. I understand that any indication of Tuberculosis must be cleared by my personal physician before I am allowed to work.
I understand that all employment related medical testing will be maintained in my Employee Health File only and will be used to validate eligibility for and continued employment.
If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the CEO.
I understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.
