MONOC New Jersey s Hospital Service Corporation

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1 MONOC New Jersey s Hospital Service Corporation APPLICATION FOR EMPLOYMENT Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, or disability, or other classification protected by applicable law. In addition, MONOC provides reasonable accommodations for applicants with disabilities. Please contact Human Resources if you require a reasonable accommodation to participate in the interview process. Please read this Application carefully and print your responses in ink. You may submit a personal resume to accompany this Application, but a personal resume will not be a substitute for answering all questions in this Application. Failure to answer all questions and to sign and date this application may result in your not being considered for employment. Name: Address: First Middle Last Telephone: ( ) - Home Address: ( ) - Cell Are you a United States citizen or otherwise authorized to work in the United States on an unrestricted basis: Yes No State age if under 18: Are you presently employed? Yes No If so, may we contact your present employer? Yes No Not until a conditional offer is accepted by me How did you hear about MONOC? Did anyone refer you to MONOC? No If yes, who? Position(s) applied for: (Please choose) EMT North South Full Time Per Diem Paramedic North South Full Time Part Time Per Diem Registered Nurse North South Full Time Part Time Per Diem Dispatcher Corporate Headquarters in Wall Full Time Part Time Instructor Locations Vary Per Diem only Other: Are you on a lay-off and subject to recall? Yes No Were you previously employed by MONOC: No If yes, when? Have you ever applied for a position with MONOC? No If yes, when? -1-

2 If you are offered a job, on what date will you be available for work? List friends or relatives presently working for MONOC. If none, please write none: List professional, trade, business or civic organizations to which you belong. (You may exclude groups which indicate race, color, religion, sex, national origin, age, marital or veteran status, or disability, or other classification protected by applicable law): Give name, address and phone number of three references not related to you: (1) (2) (3) After reading the job description at are you able to perform the essential functions of the job for which you are applying, with or without an accommodation? Yes No I did not read the job description, please provide a copy. If an accommodation is necessary, please state the accommodation needed: EMPLOYMENT EXPERIENCE List each job held. Start with your present or last job. Include self-employment, unemployment, part time jobs and military service assignments, including the particular branch you have served in, and volunteer activities. (You may exclude groups which indicate race, color, religion, sex, national origin, age, marital or veteran status, or disability, or other classification protected by applicable law). Note: a dishonorable or general discharge from military service is not an absolute bar to employment, and other factors will affect a final hiring decision. Feel free to make copies or use the reverse side for additional positions held. You may not substitute a resume in place of an application but you are welcome to attach one! Name of Employer: Department, Title and Description of Your Job: Date Employed From: to Final Salary: $ per Address of Employer: -2-

3 Supervisor Name & Title: Telephone No.: Reason for Leaving: Name of Employer: Department, Title and Description of Your Job: Date Employed From: to Final Salary: $ per Address of Employer: Supervisor Name & Title: Telephone No.: Reason for Leaving: Name of Employer: Department, Title and Description of Your Job: Date Employed From: to Final Salary: $ per Address of Employer: Supervisor Name & Title: Telephone No.: Reason for Leaving: Educational Data High School Name and Address: Graduated { } Yes { } No or GED { } Yes { } No College/University Name and Address: Graduated { } Yes { } No -3-

4 Major: Type of Degree, if Received: Graduate School Name and Address: Graduated { } Yes { } No Major: Type of Degree, if Received: Other Education/Certification/Licensures (Please explain or attach certificates): Consent & Authorization If I am employed, in consideration thereof, I agree to conform to the rules and regulations of MONOC and I recognize, understand and agree that my employment and compensation can be terminated or changed with or without cause and with or without notice, at any time, at the option of MONOC and subject to any applicable Collective Bargaining Agreement(s). I understand that no one other than the President of MONOC has the authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, and that any such agreement must be in writing and signed by the President of MONOC. I certify that answers given herein are true and complete to the best of my knowledge. To assist in evaluating my employment qualifications, I authorize MONOC and/or its designated agents to request and receive any information concerning me including but not limited to reports from any persons, schools, companies, corporations, partnerships, associations, licensing agencies, and from any of my previous employers. I also authorize any of the aforementioned parties to furnish to MONOC all information concerning me. I further release MONOC and/or its designated agents from all liability and responsibility arising out of the release of such information. Realizing that the references I give may know me by a different name, I am listing below other names by which I have been known. Other Name(s) and/or Maiden Name(s): I hereby affirm that my answers to the foregoing questions are true and correct and I understand that misrepresentation or omission of facts called for in this application, or any records, or during interview, may be cause for immediate dismissal without notice. I further understand that all applicants are subject to fingerprinting requirements, a criminal, personal, professional and educational background check, a motor vehicle report (MVR) and medical examination conducted by a physician designated by MONOC as a condition of employment. I understand that if I refuse to participate or if my results are adverse, my offer of employment will be revoked and my application will be rejected. I understand that, if I am extended an offer of employment, MONOC policies, practices, procedures, benefits, services and other materials given me are not intended to create or imply a contractual relationship between myself and MONOC except as required by law. I understand that MONOC reserves the right to amend or discontinue any policies, practices, procedures, benefits and/or services at any time, if permitted by law. I further understand that I may terminate my employment relationship with MONOC for any reason and at any time. I also acknowledge that MONOC reserves the right to terminate the employment relationship at any time and no written or oral promise of -4-

5 employment is effective unless it is expressly set forth in a document signed by the President of MONOC. Based on the needs of the organization, my days off, hours and shifts are subject to change at any time. I understand that MONOC is committed to a drug free workplace and has adopted a drug testing program to assist in implementing and enforcing that policy. I hereby consent to the taking of a urine sample by MONOC or its designated agent for the purpose of testing for such substances including but not limited to amphetamines, barbiturates, benzodiazepines (including Valium, Restoril, Xanax and Librium) cocaine, methadone, methaqualone, marijuana, opiates, methamphetamine, phencyclidine (PCP) and Propoxyphene (Darvon). I hereby consent to the release of any reports on such samples from the laboratory to MONOC and release MONOC, its officers, employees and agents from all liabilities arising from the authorized release or use of the information derived from or contained in my test results. I understand that any employment offer that is extended to me by MONOC is based on the condition that I successfully pass the drug test. I understand that if I refuse to participate or if my results are positive, my offer of employment will be revoked and my application will be rejected. The undersigned hereby authorizes MONOC or its agents to obtain and release my motor vehicle report/abstract information for MONOC s use in its risk management program. I authorize MONOC to obtain a motor vehicle background check about me periodically for insurance purposes and renewals. I understand that the information which MONOC obtains about me will be treated confidentially. MONOC may also share such information with other insurance companies for the purpose of claims handling, servicing, underwriting and auto insurance comparative shopping. I understand that I have the right to see the personal information collected about me, and the right to correct any information that may be wrong. To obtain a description of MONOC s information practices, and my rights regarding any information we collect, I know I can contact the Human Resources Department. As part of the Background Check for employment at MONOC, I understand that MONOC and/or its agents may conduct an investigation of my personal information. The investigation might include, but is not limited to names and dates of previous/current employment, work experience, workers compensation claims, criminal history records (from state, federal and other agencies), motor vehicle records, military records, names and dates of education, credit history, and bankruptcy records. I understand that these records may be used for the eligibility of my employment. I authorize without reservation the full release of these records and for MONOC s Background check vendor, HIRERIGHT and/or Verity Screening Solutions and/or its agents contacted by HIRERIGHT and/or Verity Screening Solutions to obtain information. In addition, I release and discharge HIRERIGHT and/or Verity Screening Solutions, or any third party vendor that MONOC chooses, and all of its agents and associates, any expenses, losses, damages, liabilities, or any other charges or complaints for the investigative process. I also authorize full release to MONOC of the information described above, without any reservation, throughout any duration of my employment at MONOC. I also certify that all information provided is correct on the application and my resume to the best of my knowledge. Any false statements provided will be considered just cause for termination of employment. I have the right to see the personal information collected about me, and I have the right to correct any information that may be wrong. Upon request, HIRERIGHT and/or Verity Screening Solutions or MONOC s third party vendor, will supply a copy of my report and my rights under the Fair Credit Reporting Act (FCRA). Requests for same may be directed to HIRERIGHT or Verity Screening Solutions, as well. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I authorize the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you. I also agree to -5-

6 permit MONOC to conduct substance abuse tests and any other background investigative procedures it deems appropriate with respect to my application and, in the event of hire, while employed. In the event of employment, I understand that false, incomplete or misleading information given in my application or interview(s) may result in discharge. I also understand and agree that employment shall be subject to my taking a physical examination from the MONOC physician of choice, and that in his/her opinion I must be physically and mentally able to perform the work for which I am applying or being considered, with or without reasonable accommodation. I understand, also, that I am required to abide by all rules and regulations of MONOC. This authorization shall remain valid until such time it is revoked, in writing, by the undersigned and received by the MONOC Human Resources Department. Signature of Applicant Date Print Name ** Please also include with your completed application ** A copy of your ICS, NIMS and Developmental Disabilities Awareness training, and; A copy of a current Motor Vehicle Abstract which can be obtained by visiting a local Motor Vehicle Commission office. For assistance in obtaining a New Jersey Driving Abstract please visit EMT and RN applicants should also include a copy of their transcripts from the New Jersey Department of Health and Senior Services. A copy of your CEVO Certificate. If you do not have a CEVO certificate, please contact MONOC s Career Center for information on how to obtain a CEVO certificate. Please send your application and the requested documentation via facsimile (732) , to or by regular US mail to the address listed above. Failure to submit additional documents may result in a delay of processing your application! MONOC values diversity. All applicants will be given equal consideration regardless of race, color, religion, sexual orientation, national origin, gender, age, veteran status, ancestry, marital status or disability. EOE Thank you for your interest in MONOC! We look forward to working with you in the future. -6-

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