123 PHHC

Employment Application

Date *
   
First Name *
Last Name *
Last four digits of social security number *
Street Address *
City *
State
Zip Code *
Phone Number *
Email Address
Please retype the email for verification:
Position Desired *
 Other Position
 
Requested start date *
   
Hourly Wage Desired *
Are you employed now? *
No
yes
Are you legally authorized to work in the U.S.? *
No
Yes
Ever applied to 123 PHHC before? *
No
Yes
Name of high school * Year graduated *
 
Name and address of College, course of study, years attended, and degree earned
Name and address of University, course of study, years attended, and degree earned
Name and address of technical or trade school, course of study, years attended, and degree earned
License/certification type, License/certification number, state registration, expiration
Former employer and month and year of employment * Salary *
 
Supervisor name and telephone number * Position and reason for leaving *
 
May we contact *
No
Yes
If not, why?
Former employer and month and year of employment Salary
 
Supervisor name and telephone number Position and reason for leaving
 
May we contact
No
Yes
If not, why?
Former employer and month and year of employment Salary
 
Supervisor name and telephone number Position and reason for leaving
 
May we contact
No
Yes
If not, why?
Former employer and month and year of employment Salary
 
Supervisor name and telephone number Position and reason for leaving
 
May we contact
No
Yes
If not, why?
CPR Certified *
No
Yes
Subjects of special study
Special training
Special skills
Background checks and clearances
Pa. criminal history record check
Act 33
Act 34
U.S. military service Rank
 
Drivers license number State
 
Automobile Available *
No
Yes
Automobile Insurance *
No
Yes
Ever convicted of a felony or misdemeanor crime *
No
Yes
If yes, please describe
Are you able to perform job tasks according to the job description without accommodations? *
No
Yes
If an accommodation is needed how would you perform the task and with what accommodation?
How did you hear about 123 PHHC? *
Newspaper
Magazine
Job fair
Internet
Employment agency
Employee
 Other source
 
Employee referral name
List any additional work related information you think would be helpful in considering your application for employment
Reference No. 1 Name, phone number, presession, years known *
Reference No. 2 Name, phone number, years known *
Reference No. 3 Name, phone number, years known *
Authorization *
Please check the field for confirmation.

AUTHORIZATION

I certify that the information in this application is accurate, current and complete. I understand that misstatements or omissions may result in disqualification from further consideration or termination of employment. I agree that, if hired, I may be discharged if a 123 PHHC learns of any falsification or material omission in the information you have provided and if discovered prior to hire, applicant will be considered ineligible for employment opportunities. You will not be automatically excluded from consideration if you have been convicted of a crime. Your suitability for the position sought will be evaluated based upon the circumstances such as the nature of the crime, the date of the conviction, the type of work involved, etc.

I understand and agree that all information concerning patients and their families is strictly confidential. I am not permitted to disclose any financial, medical or personal information related to any patient or family member to fellow employees, administrative staff or individuals except direct supervisor(s) at 123 PHHC.

I authorize 123 PHHC to investigate my employment history, education credentials and license verification, drivers’ record, and to obtain any relevant information, including a criminal background check needed to make an employment decision. I authorize 123 PHHC to disclose this application, performance appraisals, and disciplinary records or skills tests along with any information about me obtained during the interview process for state, federal, contractual, accreditation, or compliance purposes.

I hold harmless 123 PHHC and any individual or entity providing information to 123 PHHC from all liability for any damage from the disclosure of this information. I also understand and agree that passing a medical examination (which is my responsibility) and/or medical screening may be required. If medical restrictions cannot be reasonably accommodated, you may not be hired. If hired, you may be terminated. I understand and agree that I may be subject to pre-employment drug testing and/or alcohol testing, random testing, as well as testing where reasonable suspicion or improper usage has occurred, or where warranted by an on-the-job injury, circumstance, workplace conditions or contractual requirements.

I understand and agree nothing contained in this employment application or in granting of an interview creates an employment contract between 123 PHHC and me for either employment or for the providing of any benefit. No promises regarding employment have been made to me. If an employment relationship is established, I understand that my employment will be terminable “at will”; that is, I will have the right to terminate my employment at any time and that 123 PHHC retains the same right to terminate my employment at any time. I understand that should I become employed by 123 PHHC, my work assignments, schedules and/or work locations are subject to change according to the needs of the business and the clients of 123 PHHC.

I understand that 123 PHHC is committed to promoting consumer safety and a high standard of employee professionalism, performance, productivity and reliability. In order to achieve this, I may be subjected to a drug test prior to being hired to assure 123 PHHC that I do not currently have narcotics, sedatives, stimulants or other controlled substances and/or mood-altering substances in my system. I understand if I have any such substance in my body at the time of the drug test, 123 PHHC will not hire me.

I understand that 123 PHHC reserves the right to add, change and/or delete their policies, procedures, workplace rules and benefits at any time, and that no one in 123 PHHC has the authority to enter into any agreement for any particular period of time, or contrary to the above terms, unless that agreement is set forth in writing and signed by an authorized officers of 123 PHHC.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.”

123 PHHC is an equal opportunity employer.
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