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Application for Employment

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. We consider applicants for all positions without regard to race, color, religion, creed, gender, sexual preference, national origin, age, disability that can be reasonably accommodated without undue hardship, marital or veteran status, or any other legally protected classification.

Employment Interest

POSITION DESIRED

2ND CHOICE POSITION
TYPE OF EMPLOYMENT DESIRED:
 Full Time  Part Time  Per Diem  Temporary
If part time or per diem, specify days / hours:  

PLEASE INDICATE YOUR AVAILABILITY TO WORK:
 Days  Evenings  Nights  Any Shift  Weekends

How were you referred to Saint Michael's Medical Center?  

Identification

FIRST NAME
 MIDDLE NAME
 LAST NAME
E-MAIL ADDRESS
STREET ADDRESS
 CITY
 STATE
 ZIP
HOME PHONE
 CELL PHONE
 ALTERNATE PHONE

Previous Employment with Catholic Healthcare East

PLEASE CHECK ANY AFFILIATES OF CATHOLIC HEALTHCARE EAST AT WHICH YOU HAVE BEEN EMPLOYED:

 Columbus Hospital    Saint James Hospital  Saint Michael's Medical Center
 
Position:
Department:
Dates Employed:

PLEASE LIST ANY FRIENDS/RELATIVES EMPLOYED AT CATHOLIC HEALTHCARE EAST:

Name
Department
Relationship
Name
Department
Relationship

Legal Information

ARE YOU 18 YEARS OF AGE OR OLDER? Yes No
ARE YOU A U.S. CITIZEN OR AN ALIEN LEGALLY AUTHORIZED TO WORK IN THE UNITED STATES?
I-9 and documentation required prior to employment. Click here for I-9 clarification		 Yes No
HAVE YOU BEEN THE SUBJECT OF ANY ADVERSE ACTION(S) BY ANY DULY AUTHORIZED SANCTIONING, DISCIPLINARY OR LICENSING AGENCY FOR EITHER CONDUCT-BASED OR PERFORMANCE-BASED ISSUES? Yes No
ARE ANY PROCEEDINGS PENDING WITH REGARD TO ANY HEALTH-CARE OR PROFESSIONAL LICENSE OR STANDARDS? Yes No
HAVE YOU EVER BEEN CONVICTED OF A CRIME OR ANY OFFENSE OTHER THAN A MINOR TRAFFIC VIOLATION? Yes No
ARE ANY FELONY PROCEEDINGS PENDING AGAINST YOU? Yes No

If you answered yes to any of the above four questions, please explain:

Note: You need not list any conviction that has been expunged, sealed, or statutorily eradicated. A conviction record will not necessarily bar an applicant from employment. Factors such as relation to the job, age and time of offense, seriousness and nature of violations, and efforts at rehabilitation will be taken into account.

Education

SCHOOL NAME & ADDRESS OF SCHOOL COURSE OF STUDY DATES DID YOU GRADUATE? DIPLOMA / DEGREE
High School N/A
Yes
GED
No
College / University
Yes
No
Other
Yes
No

Professional Licenses / Certification

TYPE OF LICENSE / CERTIFICATION STATE OR ORGANIZATION EXPIRATION DATE

Skills

Check any of the following skills or knowledge that you may have:
Typing (WPM)
Transcription
Medical Terminology
Billing/Insurance Verification
Computer
Check any of the following Microsoft programs with which you are proficient:
Microsoft Word
Microsoft Excel
Microsoft Outlook
Microsoft PowerPoint
Microsoft Access
List any other skills, training, or qualifications that would support your application:

Why do you wish to work at Saint Michael's Medical Center?

What are your salary requirements? $ 

Employment

LIST PREVIOUS THREE POSITIONS BEGINNING WITH YOUR MOST RECENT:
Company Name
 Dates Main Duties and Responsibilities
Start
 End
Street Address
Scheduled Hours
City, State, ZIP
Telephone Supervisor
Final Wage Reason for Leaving
Positions Held
Company Name
 Dates Main Duties and Responsibilities
Start
 End
Street Address
Scheduled Hours
City, State, ZIP
Telephone Supervisor
Final Wage Reason for Leaving
Positions Held
Company Name
 Dates Main Duties and Responsibilities
Start
 End
Street Address
Scheduled Hours
City, State, ZIP
Telephone Supervisor
Final Wage Reason for Leaving
Positions Held
ACCOUNT FOR ALL PERIODS OF UNEMPLOYMENT DURING THE LAST FIVE YEARS:
From (Mo/Yr)     To (Mo/Yr)  
Reason: 
 
From (Mo/Yr)     To (Mo/Yr)  
Reason: 

Release Authorization

Have you ever been discharged or suspended from employment? Yes No

If yes, please explain:
Is there any employer you do not wish us to contact? Yes No

If yes, please indicate which one(s) and reason(s):

Have you been employed under any other name?		 Yes No

If yes, please identify names and dates:

Applicant Certification and Agreement

I HEREBY AUTHORIZE MY PAST AND PRESENT EMPLOYERS TO FURNISH THEIR RECORDS OF MY SERVICE TO: SAINT MICHAEL'S MEDICAL CENTER OR ANY OF ITS AFFILIATES.

I certify that the information contained in this application is correct and complete to the best of my knowledge and belief. I realize that misrepresentation of facts on this application will be cause for rejection of this application or dismissal after employment and that final employment is subject to satisfactory completion of a probationary period.

If employed by Saint Michael's Medical Center or any of its affiliates, I agree to conform to its rules and regulations. My employment may be terminated, with or without cause, and with or without notice, at any time at the option of either Saint Michael's Medical Center or myself.

I understand that no management representative has any authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.

I also understand that my employment is contingent upon my being able to pass the employment physical examination. In addition, I authorize the examining physician to give Saint Michael's Medical Center, or any of its affiliates, any information or records pertaining to my condition.

I understand that my employment in Saint Michael's Medical Center and its affiliates means that at any time when deemed necessary, I may be required to work rotating shifts or to change my regular shift upon reasonable request.

I have been informed that Saint Michael's Medical Center and its affiliates operate in compliance with the New Jersey Worker and Community Right to Know Law.




  

 

 

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