Saint Peter's Healthcare System - Employment Application

EMPLOYMENT APPLICATION

All fields marked with an * asterisk are required to be filled in. If you are unable to fill in any required information please type NA.

Full Name*

First NameMiddle NameLast NameSuffix

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

Confirmation Email

Are you under 18 years of age?*

YESNO

Position(s) applying for*

Position Req. Number:

Additional Req. Numbers:

Professional License / Certification:

Has your licensure, certification or registration by or with any federal, state or local regulatory agency or any foreign country or its agency, ever been revoked, suspended or terminated?

YesNo

Select recruiter:*

Salary desired

Referral source

Referral source (Other)

Employee referral

If related to a Saint Peter’s Healthcare System employee, state name

Have you ever been employed by Saint Peter's Healthcare System?

YesNo

If so, when?

Start date

MonthDayYear

End date

MonthDayYear

Employment desired (Select all that apply)*

Full TimePart TimePer Diem

Shifts available to work (Select all that apply)*

DayEveningNightWeekend

Will you work weekends/holidays?*

YesNo

Are you currently excluded, suspened, debarred or otherwise ineligable to particiapte in Federal or New Jersey healthcare programs?*

YesNo

Are you eligible to work in the United States?*

YesNo

Are you currently employed?*

YesNo

Date available for work*

MonthDayYear

EDUCATION

Highest level of education completed:*

Please complete the appropriate sections

	Name & Location of School	Number of Years Attended	Did You Graduate?	Degree or Certification
GED / High School
Trade School
College
Graduate

WORK HISTORY

Please list your four most recent employers, list the most recent first

1. Employer

Employer's Name (Most current)*

Address & location of business*

Your title*

May we contact this employer?*

YESNO

Supervisor's name

First and Last Name

Phone number

Area CodePhone Number

Start date

MonthDayYear

End date

MonthDayYear

Salary/Per Hour Amount

Salary or Hourly

Description of duties*

Reason for leaving*

2. Employer

Employer's Name (Second most recent)*

Address & location of business*

Your title*

May we contact this employer?

YESNO

Supervisor's name

First and Last Name

Phone number

Area CodePhone Number

Start date

MonthDayYear

End date

MonthDayYear

Salary/Per Hour Amount

Salary or Hourly

Description of duties*

Reason for leaving*

3. Employer

Employer's Name (Third most recent)*

Address & location of business*

Your title*

May we contact this employer?

YESNO

Supervisor's name

First and Last Name

Phone number

Area CodePhone Number

Start date

MonthDayYear

End date

MonthDayYear

Salary/Per Hour Amount

Salary or Hourly

Description of duties*

Reason for leaving*

4. Employer

Employer's Name (Fourth most recent)

Address & location of business

Your title

May we contact this employer?

YESNO

Supervisor's name

First and Last Name

Phone number

Area CodePhone Number

Start date

MonthDayYear

End date

MonthDayYear

Salary/Per Hour Amount

Salary or Hourly

Description of duties

Reason for leaving

ADDITIONAL INFORMATION

Do you have a U.S. military service record?*

YESNO

If yes, branch of service*

Discharge date and rank*

Specialty

Vietnam Era Veteran

YesNo

List job-related accomplishments, projects, and awards. (Exclude information that would reveal race, color, national origin, religion, gender, age, marital, or veteran status; medical condition, disability; or any other legally protected status.)

REFERENCES

List three professional references, (business or work, not relatives) that you have known for at least one year. List at least one previous supervisor.

1. Full Name*

First NameLast Name

Company*

Best phone number to reach them*

Area CodePhone Number

Years acquainted*

Professional Relationship*

2. Full Name*

First NameLast Name

Company*

Best phone number to reach them*

Area CodePhone Number

Years acquainted*

Professional Relationship*

3. Full Name

First NameLast Name

Company

Best phone number to reach them

Area CodePhone Number

Years acquainted

Professional Relationship

AUTHORIZATION

I certify that the information contained in this application is correct without omissions. I authorize the employers listed 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 liability for any damage that may result from furnishing same to you. I also understand that any statement found to be false shall be sufficient cause and reason for my immediate discharge.

I acknowledge that any offer of employment is contingent upon my satisfactorily completing the pre-placement medical examination and background checks. Such medical exam may include a pre-placement drug test. My offer of employment may be revoked if it is determined that I cannot perform the essential job functions of the position with or without a reasonable accommodation, or if providing a reasonable accommodation would impose an undue hardship on the hospital, or if my employment would pose a direct threat of substantial harm to myself or others. Additionally, I understand that the hospital reserves the right to test to determine the presence of any controlled substances such as illegal drugs or alcohol to any applicant or employee at any time; I give my consent to such tests.

I understand and agree that all accounts due to the hospital, for which I am responsible, will be paid prior to my voluntarily leaving its employ.In the event I am terminated, I understand and agree that unpaid wages and salaries can be applied to any account due the hospital for which I have assumed responsibility.

If employed by Saint Peter’s Healthcare System I agree to conform to the rules and regulations of the system. My employment may be terminated with or without cause and with or without notice at any time at the option of the hospital 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 make any agreement contrary to the foregoing. I also understand that this application is not and is not intended to be a contract of employment. No promises regarding employment have been made to me and I understand that no such promise or guarantee is binding on the hospital unless made in writing..By entering your name, you agree to accept the terms of the above document with an electronic signature.

By entering your name, you agree to accept the terms of the above document with an electronic signature.*

I agreeI do not agree

You must agree to accept the terms of the document in order to submit an application.

Type signature*

Date*

MonthDayYear

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Saint Peter’s Healthcare System is an Equal Employment Opportunity Employer and it does not discriminate in hiring or employment on the basis of race, creed, color, national origin, nationality, ancestry, age, sex (including pregnancy), marital status, domestic partnership status, affectional or sexual orientation, gender identity, atypical hereditary cellular or blood trait, genetic information, liability for military service, religion or mental or physical disability, including AIDS and HIV related illnesses or other classification protected by applicable law. SPUH will conform to the spirit as well as the letter of applicable laws and regulations.

Saint Peter’s Healthcare System is a smoke-free organization. For the health of our patients and visitors, smoking is not permitted in all buildings, parking lots and grounds. This includes electronic cigarettes.

FOR HUMAN RESOURCES DEPARTMENT USE ONLY

Employee #	Hire Date __________________	{ } New Hire { } Rehire (notify Benefit dept.)
Department Name and #: Immediate Supervisor:	Position# __________________	Position Title:
EmpStatus*	FTE	Hrs/Pay Period
Pay Rate $ Hourly: __________________ Bi-weekly: __________________	Shift:	Vacation Time Allotment:
Cert Type:	Cert Pay:	Expires: __________________
Gender (M/F):	EEOC:	Hire Source:
Clock Group:	Kronos Pay Rule:	1-9 Code: __________________	Experience Date:
Requisition #: __________________	Contract Dates: _______________	Experience Date: ____________________

PHYSICAL DATE/TIME: ______________________________________________

HOSPITAL ORIENTATION DATE/TIME: ________________________________

EMERGENCY CONTACT: NAME: PHONE: Comments: _____________________

HIRED BY: _________________________________________________________

Tracking #

E-mail