Employment Application

I certify that the information given by me in this application is true in all respects, and I agree that if the information given is found to be false in any way, it shall be considered sufficient cause for denial of employment or discharge. I authorize the use of any information in this application to verify my statements, and I authorize past employers, all references, and any other persons to answer all questions asked concerning my ability, character, reputation, and previous employment record. I release all such persons from any liability or damages on account of having furnished such information. I authorize background check including a credit history to be obtained by a consumer reporting agency. I understand that the hospital may obtain such a report and that I have a right to request that the consumer reporting agency disclose to me its report. I understand that the report may disclose information to my character, general reputation personal characteristics and mode of living.

I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Crisp Regional Hospital and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon Crisp Regional Hospital unless made in writing. If an employment relationship is established, I understand that I have the right to terminate my employment at any time and that Crisp Regional Hospital retains the same right.

I understand that prior to being offered employment with Crisp Regional Hospital I may be required to take an examination. In the event that I have a disability which will affect my ability to take the test, I will so inform Crisp Regional Hospital prior to the administration of the test so that reasonable accommodation can be made. Requested accommodations may include accessible testing sites, modified testing conditions, and accessible formats. Crisp Regional Hospital reserves the right to require medical documentation concerning the need for accommodation. I further understand that if an offer of employment is tentatively made to me, it may be conditioned upon my successful completion of a medical examination, which may include screening of controlled substances, from time to time during my employment.

I understand that if employed, policies and rules which are issued are not conditions of employment and that the employer may revise policies or procedures, in whole or in part, at any time.

I understand that this application will be kept on active file for 30 days from the date completed, after which time I would have to reapply in accordance with the established company procedures.

	Effective April 1st, 2012, as a condition of employment, Crisp Regional Hospital will not hire individuals who use tobacco in any form. A post-offer physical will include screening to detect tobacco substances in the body. When you apply for a position at Crisp Regional Healthcare Services, you agree that you will abide by the following standards: Agreement and Certification I certify that the information given by me in this application is true in all respects, and I agree that if the information given is found to be false in any way, it shall be considered sufficient cause for denial of employment or discharge. I authorize the use of any information in this application to verify my statements, and I authorize past employers, all references, and any other persons to answer all questions asked concerning my ability, character, reputation, and previous employment record. I release all such persons from any liability or damages on account of having furnished such information. I authorize background check including a credit history to be obtained by a consumer reporting agency. I understand that the hospital may obtain such a report and that I have a right to request that the consumer reporting agency disclose to me its report. I understand that the report may disclose information to my character, general reputation personal characteristics and mode of living. I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Crisp Regional Hospital and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon Crisp Regional Hospital unless made in writing. If an employment relationship is established, I understand that I have the right to terminate my employment at any time and that Crisp Regional Hospital retains the same right. I understand that prior to being offered employment with Crisp Regional Hospital I may be required to take an examination. In the event that I have a disability which will affect my ability to take the test, I will so inform Crisp Regional Hospital prior to the administration of the test so that reasonable accommodation can be made. Requested accommodations may include accessible testing sites, modified testing conditions, and accessible formats. Crisp Regional Hospital reserves the right to require medical documentation concerning the need for accommodation. I further understand that if an offer of employment is tentatively made to me, it may be conditioned upon my successful completion of a medical examination, which may include screening of controlled substances, from time to time during my employment. I understand that if employed, policies and rules which are issued are not conditions of employment and that the employer may revise policies or procedures, in whole or in part, at any time. I understand that this application will be kept on active file for 30 days from the date completed, after which time I would have to reapply in accordance with the established company procedures.
Signature	Invalid Input
Date	Invalid Input

First Name Invalid Input	Middle Name Invalid Input	Last Name Invalid Input
Address Invalid Input
City Invalid Input	State Invalid Input	Zip Code Invalid Input
Telephone No Invalid Input	Work Phone Invalid Input	Social Security Number Invalid Input

Are you 18 years of age or over?	YesNo Invalid Input
Do you have the legal right to work in the United States?	YesNo Invalid Input
Have you ever been convicted of a felony?	YesNo Invalid Input
If Yes, please explain	Invalid Input
Date available for work?	Invalid Input
Type of employment	Full timePart timeTemporary Invalid Input
Salary/Wage expected	Invalid Input
Have you applied for a job at Crisp Regional Hospital before?	YesNo Invalid Input
If yes, when?	Invalid Input
Have you ever worked for Crisp Regional Hospital before?	YesNo Invalid Input
If Yes, list job(s) held & date(s) of employment	Invalid Input
List any relative employed by Crisp Regional Hospital	Invalid Input
Education
High School Name & Location (city, state) Invalid Input	Dates Attended Invalid Input	Degree Received Invalid Input
College Name & Location (city, state) Invalid Input	Dates Attended Invalid Input	Degree Received Invalid Input
Technical or Graduate School Name & Location (city, state) Invalid Input	Dates Attended Invalid Input	Degree Received Invalid Input
Special Training Courses Name & Location (city, state) Invalid Input	Dates Attended Invalid Input	Degree Received Invalid Input
List all registrations or certifications for specialized work requirements	Description - Date - State/Country Description - Date - State/Country Invalid Input
References List your references below in the order of contact preference, starting with the most relevant one. References are individuals that are familiar with your work capabilities and your educational training. Please do not list relatives.
Reference (Name, Occupation, Address, Phone) Invalid Input	Reference 2 (Name, Occupation, Address, Phone) Invalid Input	Reference 3 (Name, Occupation, Address, Phone) Invalid Input
Employment History List each job held starting with your most recent or current employer. Include Military Assignments.
Employer Invalid Input	Supervisor Invalid Input	Address Invalid Input
Phone Number Invalid Input	Date of Hire Invalid Input	Starting Pay Invalid Input
Date Left Invalid Input	Last Pay Invalid Input	Reason for Leaving Invalid Input
Job title & Duties Invalid Input

Employer Invalid Input	Supervisor Invalid Input	Address Invalid Input
Phone Number Invalid Input	Date of Hire Invalid Input	Starting Pay Invalid Input
Date Left Invalid Input	Last Pay Invalid Input	Reason for Leaving Invalid Input
Job title & Duties Invalid Input

Employer Invalid Input	Supervisor Invalid Input	Address Invalid Input
Phone Number Invalid Input	Date of Hire Invalid Input	Starting Pay Invalid Input
Date Left Invalid Input	Last Pay Invalid Input	Reason for Leaving Invalid Input
Job title & Duties Invalid Input

Employer Invalid Input	Supervisor Invalid Input	Address Invalid Input
Phone Number Invalid Input	Date of Hire Invalid Input	Starting Pay Invalid Input
Date Left Invalid Input	Last Pay Invalid Input	Reason for Leaving Invalid Input
Job title & Duties Invalid Input
Did you hear about this job on Indeed.com	YesNo Invalid Input



Please review your application for any errors before submitting. Press Submit to forward your application for review. You will be contacted if you are selected for an interview, or you will receive notification that the position that you have applied for has been filled. Thank you for your interest in Crisp Regional Hospital.

Effective April 1st, 2012, as a condition of employment, Crisp Regional Hospital will not hire individuals who use tobacco in any form. A post-offer physical will include screening to detect tobacco substances in the body.

When you apply for a position at Crisp Regional Healthcare Services, you agree that you will abide by the following standards:

Agreement and Certification

Education

References

Employment History

Please review your application for any errors before submitting. Press Submit to forward your application for review.

You will be contacted if you are selected for an interview, or you will receive notification that the position that you have applied for has been filled. Thank you for your interest in Crisp Regional Hospital.