Healthcare Workforce Initiative                                          1111 South Edwin C. Moses Blvd.                  ...
Previous EmploymentAccount for ALL times for the past 10 years, including periods of unemployment. If you need more room, ...
Additional Previous EmploymentCompany:                                                                           Phone:   ...
Disclaimer and Signature***********************************STOP HERE—PRINT, SIGN, AND DATE APPLICATION *******************...
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Hwi application 1

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Hwi application 1

  1. 1. Healthcare Workforce Initiative 1111 South Edwin C. Moses Blvd. P.O. Box 972 Dayton, OH 45422Employment ApplicationPosition Applied for: Nursing Assistant Environmental Services Worker Nutrition Services Worker Applicant InformationFull Name: Date: Last First M.I.Address: Street Address Apartment/Unit # City State ZIP CodePhone: E-mail Address: Social Security Desired Shift: Desired Status:Date Available: No: - - 1st 2nd 3rd F/T P/T or Resource Charles F. Kettering Memorial Hospital Kettering Medical Center-SycamoreHospital Location Desired: Grandview Medical Center Southview Hospital Kettering Hospital Youth Svcs.How did you hear about the HWI Program? KMCN Employee Job Bank KMCN Website Other: EducationHigh School: Address: YES NO If not, do you YES NO Did you graduate? have a GED?College: Address: YES NO Did you graduate? Degree:Other: Address: YES NO Did you graduate? Degree: Employment ReferencesPlease list three employment references (Preferably from an immediate supervisor or manager)Full Name: Title:Company: Phone: ( ) -Address:Full Name: Title:Company: Phone: ( ) -Address:Full Name: Title:Company: Phone: ( ) -Address: Employment Application Rev. 6/30/08
  2. 2. Previous EmploymentAccount for ALL times for the past 10 years, including periods of unemployment. If you need more room, use a separatepiece of paper. A RESUME is both welcomed and urged in addition to completion of this application.Company: Phone: ( ) -Address: Supervisor:Job Title: Starting Salary: $ Ending Salary: $Responsibilities: Reason forFrom: To: Leaving: YES NOMay we contact your previous supervisor for a reference?Company: Phone: ( ) -Address: Supervisor:Job Title: Starting Salary: $ Ending Salary: $Responsibilities: Reason forFrom: To: Leaving: YES NOMay we contact your previous supervisor for a reference?Company: Phone: ( ) -Address: Supervisor:Job Title: Starting Salary: $ Ending Salary: $Responsibilities: Reason forFrom: To: Leaving: YES NOMay we contact your previous supervisor for a reference? YES NOAre you authorized to work in the U.S.?Have you ever worked for the Kettering YES NO If yes, when and at which facility?Medical Center Network?Have you ever been convicted of a crime for the violation of any law , excluding minor traffic tickets? Yes NoIf Yes, describe all of these actions, including the nature of the criminal offense(s), the location(s), the dates and their disposition.Conviction of a crime is not an automatic bar for consideration for employment. Falsification of information will result in rejection ofapplication. (If necessary, use a separate piece of paper):If yes, explain: Employment Application Rev. 6/30/08
  3. 3. Additional Previous EmploymentCompany: Phone: ( ) -Address: Supervisor:Job Title: Starting Salary: $ Ending Salary: $Responsibilities: Reason forFrom: To: Leaving: YES NOMay we contact your previous supervisor for a reference?Company: Phone: ( ) -Address: Supervisor:Job Title: Starting Salary: $ Ending Salary: $Responsibilities: Reason forFrom: To: Leaving: YES NOMay we contact your previous supervisor for a reference?Company: Phone: ( ) -Address: Supervisor:Job Title: Starting Salary: $ Ending Salary: $Responsibilities: Reason forFrom: To: Leaving: YES NOMay we contact your previous supervisor for a reference? Employment Application Rev. 6/30/08
  4. 4. Disclaimer and Signature***********************************STOP HERE—PRINT, SIGN, AND DATE APPLICATION **********************************I understand that my employment thereof is contingent upon positive results of a successful pre-placement physical, including drugscreen analysis, criminal background checks and possible fingerprinting. The result of such analysis may be grounds fordisqualifying me or terminating my employment.I authorize schools, references, my prior employers and physicians or other medical practitioners to provide my record, reason forleaving, and other information they may have concerning me to Montgomery County Department of Job & Family Services andKettering Medical Center Network and I release all parties from any and all liability to claims for damage whatsoever that may resultthere from.I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understandthat false or misleading information in my application or interview may result in my release.Signature: Date: Employment Application Rev. 6/30/08

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