Recruitment Application Form

Full Name *

First Name

Middle Initial

Last Name

N/A if there isn't any

Birth Date *

Month

Day

Year

Social Security Number *

requires a full social security number to be inputted.

Address *

Address 1 Address 2

City

State

Zip Code

Country

Phone Number *

E-mail Address *

example@example.com

Emergency Contact Person *

Relationship

Phone Number

Name

Are you age 18 or over? *

Yes

No

If you are under 18 years of age, can you provide proof of your eligibility to work? *

Do you have a legal right to work in the U.S.? *

Yes

No

You will need to provide proof of work eligibility to be employed by this facility. *

Have you ever been employed with Hill Regional Hospital before? *

Yes

No

When? *

MM-DD-YYYY

Past Position *

Reason For Departure *

Are any of your relatives (by marriage also) employed by Hill Regional Hospital? *

Yes

No

Please List Name(s) and Department(s): *

Name

Department

Have you ever been arrested and/or convicted, or are you currently awaiting disposition, for any criminal matter? *

Yes

No

When? *

MM-DD-YYYY

Location *

Offense *

Disposition *

Have you ever been terminated, or forced to resign, due to misconduct or unsatisfactory service? *

Yes

No

Explain The Circumstances *

Are you currently on “Lay Off” status and subject to recall? *

Yes

No

Can you travel, if a job requires it? *

Yes

No

Have you ever served in the United States Armed Forces? *

Yes

No

Dates *

MM-DD-YYYY

From:

MM-DD-YYYY

To:

Branch *

Type Of Discharge *

How did you hear about Hill Regional Hospital? *

Are you applying for a clinical or non-clinical position? *

Non-Clinical

Clinical

Licensed Number *

Do you have a BLS card? *

Yes

No

Do you have a ACLS card? *

Yes

No

Do you have a PALS card? *

Yes

No

BLS card expiration date? *

MM-DD-YYYY

Expiration Date

ACLS card expiration date? *

MM-DD-YYYY

Expiration Date

PALS card expiration date? *

MM-DD-YYYY

Expiration Date

Position You Are Applying For? *

Salary Desired ($) *

Shift Desired (Non-Clinical positions only) *

Days

Nights

NA

Shift Desired (Clinical positions only) *

Days

Nights

NA

Status Desired *

Full-time

Part-time

PRN

Date available for work *

MM-DD-YYYY

Are you currently employed?

Yes

No

May we contact your present employer (hiring contingent upon an accessible and favorable reference received).

Yes

No

Contact Name

Title

Email Address

example@example.com

Phone Number

Please enter a valid phone number.

Reference 1

Name of Reference

Title

Email Address

example@example.com

Phone Number

Please enter a valid phone number.

Reference 2

Name of Reference

Title

Email Address

example@example.com

Phone Number

Please enter a valid phone number.

Reference 3

Name of Reference

Title

Email Address

example@example.com

Phone Number

Please enter a valid phone number.

Employer 1 *

Name of Current Employer or NONE if not Employed

Title *

Paid Hourly or Salary? *

Hourly

Salary

Hourly Rate($) *

Salary($) *

Reason for Leaving? *

City *

State *

Primary Job Duties *

Supervisor *

Start Date *

MM-DD-YYYY

End Date *

MM-DD-YYYY

May we contact? *

Yes

No

Employer 2 *

Name of Current Employer or NONE if not Employed

Title *

Paid Hourly or Salary? *

Hourly

Salary

Hourly Rate($) *

Salary($) *

Reason for Leaving? *

City *

State *

Primary Job Duties *

Supervisor *

Start Date *

MM-DD-YYYY

End Date *

MM-DD-YYYY

May we contact? *

Yes

No

Employer 3 *

Name of Current Employer or NONE if not Employed

Title *

Paid Hourly or Salary? *

Hourly

Salary

Hourly Rate($) *

Salary($) *

Reason for Leaving? *

City *

State *

Primary Job Duties *

Supervisor *

Start Date *

MM-DD-YYYY

End Date *

MM-DD-YYYY

May we contact? *

Yes

No

By signing this application, I certify that all answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. Any omissions or misstatements of facts may be cause for rejection of this application or discharge from employment.

I understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with Hill Regional Hospital is of an “at will” nature, which means that the employee may resign at any time and the employer may discharge employee at any time with or without cause.

I authorize Hill Regional Hospital Human Resources Department, or its designee, to make all necessary and appropriate investigations, allowable by law, to verify the information concerning my professional and personal background. It is my responsibility to update the Human Resources Department of any changes of my information.

Applicant's Printed Name: Date:

(Please read and sign this form in the space provided below. Your written authorization is necessary for completion of the application process.)

I, , hereby authorize Hill Regional Hospital to investigate my background and qualifications for purposes of evaluating whether I am qualified for the position for which I am applying. I understand that Hill Regional Hospital will utilize an outside firm or firms to assist it in checking such information, and I specifically authorize such an investigation by information services and outside entities of the company's choice. I also understand that I may withhold my permission and that in such a case, no investigation will be done, and my application for employment will not be processed further.

Employment Application

PERSONAL DATA:

EMPLOYMENT DESIRED:

EDUCATION:

TRAINING/SKILLS:

Business References:

EMPLOYMENT HISTORY:

Resume: *

Clinical License: *

School/Graduate (Diploma/G.E.D) Certifications: *

BLS: *

ACLS: *

PALS: *

ACKNOWLEDGEMENT

AUTHORIZATION

Electronic Signature (Sign here) *

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