EMPLOYMENT APPLICATION

Transcription

1 EMPLOYMENT APPLICATION Human Resources Department 30 Shelburne Road, P.O. Box 9317, Stamford, CT (203) TDD Only - (203) An Equal Opportunity Employer M/F/D/V It is the policy of Stamford Hospital to seek and employ the best qualified personnel in every job without unlawful regard to race, color, religion, gender, sexual orientation, marital status, national origin, ancestry, age or physical or mental disability, consistent with individual skills and the needs of Stamford Hospital. You may request any needed accommodation to participate in the application process. PLEASE PRINT LAST NAME FIRST NAME MIDDLE INITIAL OTHER NAME USED PERSONAL ADDRESS (NUMBER AND STREET). YRS. AT SOCIAL SECURITY NUMBER CURRENT ADDRESS CITY STATE ZIP CODE PHONE NUMBER ADDRESS MOBILE NUMBER PERMANENT ADDRESS NUMBER AND STREET CITY STATE ZIP CODE GENERAL U.S. CITIZEN OR AUTHORIZED TO WORK IN U.S.? BRANCH OF SERVICE S FROM TO SELECTIVE SERVICE CLASSIFICATION MILITARY OCCUPATION OF SERVICE HOW DID YOU HEAR OF THIS POSITION? DO YOU HAVE ANY RELATIVES WORKING AT STAMFORD HOSPITAL (IF, GIVE NAME, ADDRESS AND RELATIONSHIP) POSITION APPLIED FOR AVAILABLE SALARY REQUIREMENTS HAVE YOU EVER WORKED FOR STAMFORD HOSPITAL? WHERE AND WHEN NAME AND LOCATION OF SCHOOL CIRCLE HIGHEST YEAR GRADUATED COURSE OR MAJOR EDUCATION HIGH SCHOOL COLLEGE OTHER PROFESSIONAL OR TECHNICAL LICENSE. EXPIRATION & STATE LICENSE. EXPIRATION & STATE LICENSE. EXPIRATION & STATE LICENSES/CERTIFICATIONS HELD REFERENCES ( RELATIVES OR PERSONAL REFERENCES PLEASE) MAY WE CONTACT YOUR CURRENT EMPLOYER? T APPLICABLE

2 (LIST MOST RECENT EMPLOYMENT FIRST) 1) NAME OF EMPLOYER EMPLOYMENT 2) NAME OF EMPLOYER 3) NAME OF EMPLOYER My signature below indicates that I understand and agree with all of the following statements: Nothing contained in this application or in the employee handbook, shall be deemed to create an employment contract between Stamford Hospital and myself for either employment or for the providing of any benefit. The granting of an interview shall likewise not create such a contract. No promises regarding employment or inducements to take employment have been made or offered to me and I understand and agree that no such promises are binding upon Stamford Hospital unless made in writing and signed by the President and Chief Executive Officer of Stamford Hospital. If an employment relationship is hereafter established, I understand and agree that I have the right to terminate my employment at any time for any reason and that the employing organization retains a similar right. My employment is contingent upon the satisfactory completion of a physical examination, including testing for illegal use of drugs, and satisfactory references. I hereby give Stamford Hospital to which I am applying for employment and its agents permission to undertake a verification of the information I have provided, to investigate regarding any criminal records and to investigate previous employment, educational background and references, and release them from any liability and responsibility from doing so. Pursuant to Section f of the Connecticut General Statutes, I hereby release all parties supplying references and other personally identifiable information from any liability or damage whatsoever arising therefrom. Any intentional misrepresentation in the employment process may lead to my dismissal.

3 STAMFORD HOSPITAL STAMFORD, CT TICE TO APPLICANT BEING CONSIDERED FOR EMPLOYMENT SUBSTANCE ABUSE TESTING Stamford Hospital has a firm commitment to providing a safe work place. Our commitment to our patients and employees health and safety requires that stringent safety standards be met. Therefore, it is our intention to provide and maintain a drug and alcohol-free environment in which to provide health services. After the Human Resources Department provides the candidate with a conditional offer of employment, a physical examination is mandatory. The routine physical examination that is given to all candidates for employment includes urine screening for the presence of drugs. If the physical examination establishes the use of a drug other than one legally used pursuant to a doctor s prescription or as directed over-the-counter, employment will be denied. Upon request, candidates who are denied employment based upon the results of the drug tests will be given copies of the test results. I hereby authorize release to Stamford Hospital, of the results of any drug screening tests I undergo pursuant to my application for employment with Stamford Hospital. I have read and understand the above notice as it relates to my application for employment with Stamford Hospital.

4 STAMFORD HOSPITAL STAMFORD, CT TICE TO APPLICANT BEING CONSIDERED FOR EMPLOYMENT Have you ever been convicted of a crime? (A conviction will not necessarily be a bar to employment.) Yes No If you answered yes, please describe the nature of the offense, the date of the convictions and the nature of any rehabilitation. Note: You are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to Connecticut General Statutes Sections 46b-146, 54-76o or a. Criminal records subject to erasure pursuant to Connecticut General Statutes 46b-146, 54-76o or a are records related to (a) determinations of delinquency or that, as a child, you were a member of a family with service needs, (b) a ruling you are a youthful offender, (c) a criminal charge that has been dismissed or knolled: (d) finding you are not guilty for a criminal charge, or (e) a conviction for which you have received an absolute pardon. Any person whose criminal records have been erased pursuant to Connecticut General Statutes Sections 46b-146, 54-76o or a shall be deemed to never have been arrested within the meaning of the general statutes with respect to the proceedings so erased and may so wear under oath. BACKGROUND VERIFICATION DISCLOSURE As part of the employment process, Stamford Health System may obtain a Consumer Report and/or an Investigative Consumer Report. The Fair Credit Reporting Act as amended by the Consumer Reporting Reform Act of 1996 requires that we advise you that for purposes of employment only, a Consumer Report may be made which may include information about your credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided, in the event the report contains information regarding your character, general reputation, personal characteristics, or mode of living. I also understand that before I am denied employment based, in whole or part, on information obtained in the report, I will be provided a copy of the report and a description in writing of my rights under the Fair Credit Reporting Act. AUTHORIZATION AND RELEASE During the application process and at any time during any subsequent employment, I hereby authorize Stamford Health System or its agents on behalf of Stamford Health System to procure a Consumer Report which I understand may include information regarding my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. This report may be compiled with information from credit bureaus, court record repositories, departments of motor vehicles, past or present employers and educational institutions, governmental occupational licensing or registration entities, business or personal references, and any other source required to verify information that I have voluntarily supplied. I understand that I may request a complete and accurate disclosure of the nature and scope of the background verification; to the extent such investigation includes information bearing on my character, general reputation, personal characteristics or mode of living. I understand if I disagree with the accuracy of any information in the report, I must notify Stamford Hospital within five business days of my receipt of the report. If I notify Stamford Hospital within five business days of the receipt of the report that I am challenging information in the report, Stamford Hospital will not make a final decision on my employment status until after I have a reasonable opportunity to address the information contained in the report. I hereby consent to this investigation and authorize Stamford Hospital to procure a report on my background as stated from a consumer reporting agency.

5 Pre-Offer Invitation to Self-Identify Name: _ of Application: Position Applying For: _ Stamford Hospital is an Equal Opportunity Employer, and does not discriminate on the basis of race, religion, color, sex, age, non-disqualifying physical or mental disability, national origin, or any other basis covered by appropriate law. All employment is decided on the basis of qualifications, merit, and business need. In order to comply with certain governmental recordkeeping, Stamford Hospital invites applicants to voluntarily selfidentify their race or ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual. Check one: Male Female Check one of the following: Race/Ethnic Group: I choose not to self-identify Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment. Two or More Races (Not Hispanic or Latino) A person who identifies with more than one of the above five races. Revised 07/02/09