Cathedral Healthcare System - Employment Application

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 Cathedral Healthcare System

PLEASE CHECK ANY AFFILIATES OF CATHEDRAL HEALTHCARE SYSTEM 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 CATHEDRAL HEALTHCARE SYSTEM:

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

College / University

Yes

Other

Yes

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 Cathedral Healthcare System?

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: CATHEDRAL HEALTHCARE SYSTEM 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 Cathedral Healthcare System 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 Cathedral Healthcare System 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 Cathedral Healthcare System, or any of its affiliates, any information or records pertaining to my condition.

I understand that my employment in Cathedral Healthcare System 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 Cathedral Healthcare System and its affiliates operate in compliance with the New Jersey Worker and Community Right to Know Law.


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