EMPLOYMENT APPLICATION

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1 NAME/Last, First, Middle POSITION DATE EMPLOYMENT APPLICATION 2222 Welborn Dallas, Texas (214) (800) , ext Texas Scottish Rite Hospital for Children is an equal opportunity employer and does not discriminate against applicants or employees because of race, color, religion, national origin, sex, age, disability status of otherwise qualified individuals, military status or any other status protected by law. For further information, please contact: Provider Name: Texas Scottish Rite Hospital for Children Contact: Director of HR Telephone number: (214) Contact: Administrator Telephone number: (214) TDD or State Relay number: 1-(800)

2 LAST NAME: FIRST: MIDDLE: IF YOU ARE KNOWN SCHOOLS, PAST EMPLOYERS, LICENSING AGENCIES OR REFERENCES BY ANOTHER NAME, PLEASE LIST ALTERNATE NAME: PREVIOUS RESIDENCES FOR LAST FIVE YEARS (Use an additional sheet if necessary): EDUCATION / SKILLS PERSONAL POSITION APPLIED FOR: SALARY DESIRED: HAVE YOU EVER BEEN EMPLOYED BY TEXAS SCOTTISH RITE HOSPITAL FOR CHILDREN? YES NO DATE OF EMPLOYMENT: REASON FOR LEAVING: ARE YOU APPLYING FOR: FULL-TIME WOULD YOU CONSIDER WORKING ANY SHIFT? YES NO PART-TIME WEEKENDS AND HOLIDAYS? YES NO TEMPORARY ROTATING SHIFTS? YES NO ON CALL? YES NO SHIFT PREFERENCES: 1 ST 2 ND 3 RD WHAT ARE YOUR LONG-TERM OCCUPATIONAL GOALS? ARE YOU LEGALLY ENTITLED WORK IN THE UNITED STATES? YES NO IF EMPLOYED, YOU WILL BE REQUIRED PROVIDE DOCUMENTATION OF CITIZENSHIP AND/OR RESIDENCY STATUS. HAVE YOU EVER BEEN CONVICTED OF ANY CRIME OTHER THAN A MINOR TRAFFIC VIOLATION? YES NO IF YES, PLEASE EXPLAIN. (CONVICTION WILL NOT NECESSARILY DISQUALIFY ANY APPLICANT EMPLOYMENT. RELEVANT FACRS SURROUNDING YOUR CONVICTION, SUCH AS SERIOUSNESS AND NATURE OF THE OFFENSE, WILL BE CONSIDERED IN RELATION SPECIFIC JOB REQUIREMENTS.) HAVE YOU EVER BEEN CHARGED WITH CHILD NEGLECT, ABUSE OR ANY CRIME INVOLVING A CHILD? YES NO IF YES, PLEASE EXPLAIN. SCHOOL SCHOOL NAME COURSE STUDY DIPLOMA OR DEGREE YEAR COMPLETED HIGH SCHOOL N/A COLLEGE COLLEGE OTHER Business College, Other Special Courses: (Include Special Military Training, Post-Graduate and Nursing) AREA OF SPECIALIZATION OR MAJOR INTEREST: TYPING: APPROX. WPM LIST HEALTHCARE, BUSINESS OR INDUSTRIAL EQUIPMENT OPERATED: PROFESSONAL LICENSES AND/OR CERTIFICATIONS (Check those that apply.) ARE YOU CURRENTLY? REGISTERED LICENSED CERTIFIED ELIGIBLE FOR? REGISTRATION LICENSURE CERTIFICATION IF REGISTERED, LICENSED OR CERTIFIED: TYPE STATE ISSUED DATE NUMBER TYPE STATE ISSUED DATE NUMBER

3 PLEASE LIST NAME, ADDRESS AND PHONE NUMBER OF PREVIOUS EMPLOYERS, WITH MOST RECENT EMPLOYER FIRST. TAL HOURS WORKED PER WEEK: SUPERVISOR: TAL HOURS WORKED PER WEEK: SUPERVISIOR: TAL HOURS WORKED PER WEEK: SUPERVISIOR: TAL HOURS WORKED PER WEEK: SUPERVISIOR: PREVIOUS EXPERIENCE PLEASE EXPLAIN ANY EMPLOYMENT GAPS IN YOUR WORK HISRY LONGER THAN ONE MONTH: LIST ANY OF THE ABOVE EMPLOYERS YOU DO NOT WANT US CONTACT: DID YOU SERVE IN THE U.S. ARMED SERVICES? YES NO BRANCH OF SERVICE: BRIEFLY DESCRIBE DUTIES AND SKILLS ACQUIRED IN THE SERVICE (INCLUDE DATES): HAVE YOU EVER BEEN TERMINATED OR ASKED RESIGN A JOB? YES NO IF YES, PLEASE EXPLAIN:

4 HOW WERE YOU MADE AWARE OF THIS POSITION? AD POSTING EMPLOYEE OTHER BILINGUAL SKILLS (beneficial for some positions) LANGUAGE(S): PLEASE MAKE ANY REMARKS THAT YOU FEEL ARE PERTINENT YOUR APPLICATION: APPLICANT S SIGNATURE OPTIONAL INFORMATION _ I certify that the information contained in this application is true and complete. I understand that any omission, falsification or misrepresentation in this application will be considered sufficient reason to disqualify me for consideration for employment, or if I am hired, sufficient reason for disciplinary action, up to and including discharge from employment. I authorize Texas Scottish Rite Hospital for Children to investigate fully my suitability for employment. In order to evaluate me for employment purposes, I authorize the hospital to contact any or all of my previous employers, references and educational institutions unless otherwise indicated. I further authorize the hospital to investigate my character, general reputation, personal characteristics, mode of living, work habits, skills and/or ability through any consumer reporting agency of its choice. In connection therewith, and in consideration of the undertaking of the hospital to review this application for employment and consider me for hire, I hereby release the hospital from any liability whatsoever for any damage that I may suffer or sustain by reason of the use of such report or information. I understand that under federal law, I may be entitled to request in writing the disclosure of the nature and scope of certain aspects of the hospital s investigation. I understand that the results of any such investigation may be disclosed to hospital personnel involved in the employment decision, and I consent to such disclosure. If hired, I agree to conform to the rules and regulations of the hospital and understand that any such employment is at will and can be terminated at any time, with or without cause, at the option of the hospital or myself. Date Signature

5 APPLICATION DISCLOSURE Pursuant to the requirements of the Fair Credit Reporting Act, notice is given that a consumer report may be made in connection with your application for employment and/or that periodic consumer reports may be made in connection with your continued employment if you are employed by Texas Scottish Rite Hospital for Children. If you are denied employment, either wholly or partly, because of information contained in a consumer report, or if your continued employment is terminated or restricted because of such information, a disclosure will be made to you of the name and address of the consumer reporting agency making such report. You will also receive a copy of the report and a statement of your consumer rights. I have read the above notice and understand what it means. I hereby authorize the procurement of a consumer report for employment purposes. Date Applicant Signature Social Security Number Date of Birth

6 INFORMATION APPLICANTS I acknowledge receipt of my personal copy of Information to Applicants as it appears below. Applicant s Name: (Please Print) Applicant s Signature: Date: Texas Scottish Rite Hospital for Children (TSRHC), as an equal opportunity employer, complies with all federal and state regulations. Texas Scottish Rite Hospital for Children is an equal opportunity employer and does not discriminate against applicants or employees because of race, color, religion, national origin, sex, age, disability status of otherwise qualified individuals, military status or any other status protected by law. TSRHC is a drug-free workplace. I understand that any offer of employment is conditioned upon my submission to a drug screening test. I acknowledge that I will not be employed if the drug test result is positive for any illegal drug, if I tamper with the drug test in any way or refuse to submit to the test. I understand that I may obtain a copy of the hospital s substance abuse policy from the People Department. I acknowledge and agree that this employment application is not a contract or legal guarantee of permanent employment. If I am hired by TSRHC, my employment is not for any specific time and may be terminated at any time, either by me or the hospital with or without reason or advance notice. No officer, employee or representative of the hospital other than the president or executive vice president and administrator has the authority to enter into any agreement for employment for a specific period of time or to make any statement contrary to the provisions outlined in this paragraph. This application contains an authorization for the hospital to investigate my employment and personal history by obtaining information from the previous employers as to their firsthand experience with me and also, when deemed necessary, by obtaining reports from credit reporting agencies. Under some circumstances, such reports may be Consumer Reports or Investigative Consumer Reports as to which, under the Fair Credit Reporting Act, I am entitled, upon my request in writing, to receive a complete and accurate disclosure of the nature and scope of the investigation required by the hospital. This application will remain under consideration for one to two months from the date of submission. At the conclusion of that period, if I still wish to be considered for employment, I must reapply by completing a new application for employment. Information regarding my date of birth is required solely for use by Group One Services in conducting background checks on applicants for employment. This information is not a part of my application for employment. White Copy- People Department Yellow Copy- Applicant

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