Health Central - Application

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Today's Date:	Jul 23, 2008
Applicant Name:	Last First M.I.
Current Address:
City:		State: Zip Code:
Social Security:		Email Address:
Contact Phone:	- -	Cell Phone:	- -

Applicant Note:

This application form is intended for use in evaluating your qualifications for employment. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment, terminating employment. All qualified applicants will receive consideration without discrimination because of sex, marital status, race, age, creed, national origin or the presence of disabilities. A felony conviction will not necessarily bar an applicant from employment. Affirmative action hiring may be requested by qualified applicants. Additional testing of job related skills and for the presence of drugs in your body may be required prior to employment. After an offer of employment, and prior to reporting to work, you are required to submit to a medical review. Depending on company policy and the needs of the job, you will be required to complete a medical history form and may be required to be examined by a medical professional designated by the company.

Have you ever been employed with West Orange Healthcare District or any other entities known as West Orange Memorial Hospital, West Orange Manor, Paramedic Services, Express Care, Health Central or Health Central Park? Yes No
If yes, When?
What prompted your application with Health Central? Newspaper Ad Internet Job line Posting Employee referral (Name: ) Other

Availability:

Position Applying for:
Schedule Preferences:	Full Time Part Time Temporary Labor Pool Weekdays Weekends Evenings Nights Overtime Shift Other

Education:

Please check the highest grade completed?

	7		8		9		10		11		12
	13		14		15		16		16+

Name

City/State

Graduate

High School

College

Other

Security:

List states and counties of residence for the past seven (7) years:
Have you used any names or Social Security numbers other than those on this page? Yes No If yes, please specify:
Have you ever been convicted of, sentenced for or plead Nolo Contendere to a felony? Yes No If so, please describe below. (In accordance with company policy this information will be reviewed for job relatedness and time since last conviction.)
Incident	City / State	Charge

Job Related Skill:

(DO NOT fill out any part of this sections you believe to be non-job related.)

List any languages in which you are fluent:

If the job requires, do you have the appropriate valid driver�s license?
Yes No
Driver�s License No.: Class:
State issued:
Have you had any moving violations? Please describe:

Please list any other skills, licenses or certificates that may be job related or that you feel would be of value to this job or company:

Employment References:

Your application will not be considered unless every question in this section is answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are critical.

Most Recent Employer
Are you currently working for this employer? Yes No If yes, may we contact? Yes No
Company Name
City State Phone Number - -
From -
To -
Job Title	Supervisor's Name
Duties:
Salary (Hrly, Wkly, Mthly)	Reason for Leaving:
Second Most Recent Employer
Are you currently working for this employer? Yes No If yes, may we contact? Yes No
Company Name
City State Phone Number - -
From -
To -
Job Title	Supervisor's Name
Duties:
Salary (Hrly, Wkly, Mthly)	Reason for Leaving:
Third Most Recent Employer
Are you currently working for this employer? Yes No If yes, may we contact? Yes No
Company Name
City State Phone Number - -
From -
To -
Job Title	Supervisor's Name
Duties:
Salary (Hrly, Wkly, Mthly)	Reason for Leaving:

References:

Include only individuals familiar with your work ability. Do not include relatives.

Name	Address / Phone	Years Known / Relationship

Comments:

West Orange Healthcare District Service Standards

Health Central is dedicated to improving the health of our community with an emphasis on patient/resident satisfaction. As a direct caregiver or support staff, every team member, agency staff, contract personnel and volunteer plays a vital role in positively impacting satisfaction.

These Six Service Standards are the criterion by which we measure the quality of our care and ultimately the satisfaction of our patient/resident, family member and team members.

We want to welcome you to Health Central and may the talent you share with our patients/residents, family members and team members continue to communicate that we are People Caring for People!

To be personally prepared daily to represent Health Central with a professional look and a CARING attitude.
Provide warm and gracious greeting to everyone we come in contact with, thus creating a CARING environment at Health Central.
Seek to anticipate and understand patient/resident, family member, and team member needs; and then provide appropriate service in a CARING way.
Take a vigorous approach to improving the experience and resolving issues in a way that demonstrates a commitment to CARING for people.
Individualize the Health Central experience by providing the highest quality healthcare and CARING enough to understand the specific wants and needs of each patient/resident, family member and team member.
Create a lasting impact that will leave everyone we come into contact with the knowledge that Health Central is about People CARING for People.

My signature below indicates that I have read, understand and will apply the Six Service Standards while employed by, contracted by, volunteering for or acting on behalf of Health Central and/or the West Orange Healthcare District.

Certification and Release:

I certify that I have read and understand the applicant note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to a drug testing to detect the use of illegal drugs prior to and during employment.

I have read and understand the Applicant Note and Certification and Release.
by entering your initials you agree to the terms as stated in the Applicant Note and Certification and Release.