Date of Application:      Date Available:

Name

Last    First   Middle

email:

Present Address

Street City  State Zip

Phone Number

Permanent Address (if different than Present Address)

Street City  State Zip

Phone Number

If you cannot be reached at the above numbers, where may we contact you?

Name of Person     Phone Number

If hired, can you provide proof that you are eligible to work in the United States?

Employment Desired

Position Applying For:

First Choice Shift Salary

Second Choice Shift Salary

Third Choice Shift Salary

Will you accept employment of

Full Time? Part Time?

Are you employed at this time? Yes No

May we contact your employer? Yes No

If no, why?

How did you hear of this opening?

If under 18, do you have a NY State Student Employment Certificate? Yes No

Education

Highest grade completed?   Scholastic honors received?

Grammar or Grade School

Name of School Location (City, State)

Date Completed Type of Degree Earned

High School

Name of School Location (City, State)

Date Completed Type of Degree Earned

College

Name of School Location (City, State)

Date Completed Type of Degree Earned

Vocational or Business School

Name of School Location (City, State)

Date Completed Type of Degree Earned

Extracurricular activities or other qualifications you have that you feel are related to the
position for which you are applying:

Have you ever been in the US Armed Forces? Yes No

Type of training obtained pertinent to position?

Professional Licenses and/or Certifications

Type of Certificate Issued by Date Issued

Number

Are you related to anyone in our employment? Who and how?

Have you ever filed an application before? Yes No If yes, when?

Have you been employed here before? Yes No If yes, when?

Employment Record

Employer #1
Name Address Phone

Dates Employed: From To

Job Title

Hourly Rate/Salary: Start Final

Duties Performed:

Supervisor

Reason for Leaving:

Employer #2
Name Address Phone

Dates Employed: From To

Job Title

Hourly Rate/Salary: Start Final

Duties Performed:

Supervisor

Reason for Leaving:

Employer #3
Name Address Phone

Dates Employed: From To

Job Title

Hourly Rate/Salary: Start Final

Duties Performed:

Supervisor

Reason for Leaving:

Employer #4
Name Address Phone

Dates Employed: From To

Job Title

Hourly Rate/Salary: Start Final

Duties Performed:

Supervisor

Reason for Leaving:

Personal References

Name: Address: Phone: Business:

Name: Address: Phone: Business:

Name: Address: Phone: Business:

Name: Address: Phone: Business:

If you have additional references or work history, please add them in the space below.

Please explain all periods of unemployment:

If your references, education or military service records are under another name other than indicated on the front of application, please indicate below:

Last: First: Middle Initial:

Have you ever been convicted of a crime? Yes No       What type:
(Convictions will not automatically disqualify an applicant for a particular job. All aspects of an applicant's history will be considered.)

Are you able to perform the essential duties of the jobs for which you have applied, with or without accommodation? Yes No

If no, please describe any tasks which you are NOT able to perform with or without an accommodation:

Employment Disclaimer:

I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies, or corporations supplying such information. I also understand that there will be a criminal background check as part of the hiring procedure.

After a tentative offer of employment has been made, I agree to take a medical examination at no personal expense and authorize the examining physician to disclose the findings to the Company.

I understand that I will be required to follow the personnel policies and rules of the Baptist Health System and that infractions of said rules may lead to dismissal. I also understand that any employment may be terminated for any misstatement or omission of said appearing on the application form, or physical examination form.

I understand that this institution follows the "fair employment practice code" and "the fair housing code" and that there is no discrimination in the hiring of individuals or the housing of individuals.

I understand that this application is not intended as a contract of employment. I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time, with or without notice, for any reason.

I acknowledge that I have read the above disclaimer

Date: