Employment | Sharon Regional Health System

Employment
SHARON REGIONAL HEALTH SYSTEM
SHARON, PENNSYLVANIA

APPLICATION FOR EMPLOYMENT
Sharon Regional Health System is an Equal Opportunity Employer. We consider applicants for all positions without regard to race, color, religion, creed, sex, national origin, ancestry, age, disability, veteran status, or any other status protected by federal, state or local law.

DATE:
POSITION APPLIED FOR:
	FIRST CHOICE	SECOND CHOICE
NAME:
	LAST	FIRST	MIDDLE
ADDRESS:
	Street Address	City	STATE	ZIP CODE

	PHONE NUMBER	ALTERNATE NUMBER

HAVE YOU EVER WORKED OR ATTENDED SCHOOL UNDER ANOTHER NAME?				YES	NO
IF YES, PLEASE STATE THE NAME:
DID YOU EVER APPLY HERE BEFORE?	YES	NO	IF YES, WHEN?
WERE YOU EVER EMPLOYED HERE BEFORE?	YES	NO		IF YES, WHEN?

HAVE YOU EVER BEEN CONVICTED OF A FELONY?	YES	NO		If "Yes", please describe fully the criminal conviction(s), listing the nature of the offense(s) and your rehabilitation since the conviction(s).
Note: This question does not apply to convictions that have been expunged, sealed, pardoned, or otherwise exonerated or eradicated. (A conviction record will not necessarily be a bar to employment. A conviction which is substantially related to the functions or qualifications of the position(s) for which you are applying may be taken into consideration.) If "Yes", please describe fully the criminal conviction(s), listing the nature of the offense(s) and your rehabilitation since the conviction(s).

WILL YOU WORK:	FULL TIME	PART TIME
	DAYS	NIGHTS	AFTERNOONS	ROTATE
	WEEKENDS	PER DIEM
ON WHAT DATE WILL YOU BE AVAILABLE TO WORK?

NAME OF SCHOOL	COMPLETE ADDRESS	ACADEMIC MAJOR	YEARS COMPLETE	DEGREES	GRADE AVG.
Last Elementary School:


Last High School:


Jr. College, College:


Nursing School/Technical/ Vo-Tech/Other:

EDUCATION
Other details of experience or training; include information on adult education programs.
Currently taking course?	YES	NO
PROFESSIONAL LICENSES AND /OR CERTIFICATES

Type	State Issued		Date	No.

Type	State Issued		Date	No.

Type	State Issued		Date	No.
WORK EXPERIENCE
Give a complete record of all employment and reasons for periods unemployed. Start with the most recent employment. If employed as a Registered Nurse, list type of nursing experience under " Position ". (e.g. General Medical Surgical).
Dates of Employment:	thru
Name of Employer:
Address:
Telephone Number:
Salary:
Position:
Supervisor:
Reason for Leaving:

Dates of Employment:	thru
Name of Employer:
Address:
Telephone Number:
Salary:
Position:
Supervisor:
Reason for Leaving:

Dates of Employment:	thru
Name of Employer:
Address:
Telephone Number:
Salary:
Position:
Supervisor:
Reason for Leaving:

Dates of Employment:	thru
Name of Employer:
Address:
Telephone Number:
Salary:
Position:
Supervisor:
Reason for Leaving:
If there is a present employer, may we contact the employer ?			YES	NO
If no, please list reason
PERSONAL REFERENCES
Please do not list relatives, previous employers or anyone you have known less than one year.

Name/Occupation			Address

			Phone Number

Name/Occupation			Address

			Phone Number

Name/Occupation			Address

			Phone Number

Name/Occupation			Address

			Phone Number

I understand that this application is not a contract, offer, or promise of employment. By filling out this application I am genuinely interested in working for Sharon Regional Health System and understand an offer of employment may be subject to receipt of satisfactory reports and the accuracy of all pre-employment information I have supplied. I acknowledge that employment with Sharon Regional Health System is on an at-will basis. I am free to terminate my employment with Sharon Regional Health System at any time for any reason. Similarly, Sharon Regional Health System is free to terminate the employment relationship at any time, with or without cause or advance notice. Acceptance of employment is not a contract of employment for any specific time.

I understand that after a conditional offer of employment, I will be required to undergo and satisfactorily pass a medical
examination. I also understand that Sharon Regional Health System has a drug and alcohol free workplace, including a drug and/or alcohol testing program consistent with the applicable federal, state and local law. If I am offered a conditional offer of employment, I understand that if pre-employment (post-offer) drug and/or alcohol test is positive, the employment offer may be withdrawn. I agree to work under Sharon Regional Health System's conditions requiring a drug and alcohol free workplace. I also understand that all employees of the location, pursuant to Sharon Regional Health System's policy and/or federal, state and local law, may be subject to urinalysis, breath, blood screening and/or other medically recognized tests designed to detect the presence of alcohol or controlled drugs. If employed, I understand that taking of drug and/or alcohol tests is a condition of continual employment and I agree to undergo such testing consistent with Sharon Regional Health System's policies and applicable federal, state and local law.

If employed, I will be required to abide by Sharon Regional Health System's rules and regulations, consistent with applicable federal, state, and local law. I understand that Sharon Regional Health System has the discretion to modify its policies, rules, regulations and practices at any time, to the extent allowed by federal or state law, except that it will not modify its policy of employment at-will. By my continued employment with Sharon Regional Health System, I consent to any changes.

I hereby authorize Sharon Regional Health System or it's agents to verify all statements contained in this application and/or resume to the extent permitted by federal, state or local law. (Federal law and some state laws require a separate disclosure and consent form when obtaining consumer credit reports). To the extent permitted by federal, state or local law, I release all parties from any liability arising out of this provision and the use of such information.

I certify that the above information is complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation or omission of information in this application and/or resume relating to my application of employment may result in denial of my employment, or if employed, my immediate dismissal.

By typing my name in the space provided below for a signature, I am signing this application.
Applicant's Signature: Date:

For more Information call our Health Information Center at :

724-983-5518 or 800-346-7997