Job Application





Employment Application – Pioneers Medical Center:
PROVIDE ONLY THE INFORMATION REQUESTED. FAILURE TO DO SO WILL RESULT IN DISQUALIFICATION OF YOUR APPLICATION.

In compliance with Federal and State employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, sexual orientation, ancestry, creed, veteran status or the presence of a non-job-reated medical condition or disability.

Note: If you leave this application before clicking on the Submit Application button at the bottom of the page, all information you entered prior to leaving will be lost. As a safeguard, you should print the application before submitting it. If you do not get a Message Sent Successfully confirmation message after clicking on the Submit Application button, fax the printed copy to Pioneers Medical Center’s Human Resource Department.

Availability and Salary Requirement

Date available for employment:

Social Security Number:

Name, Address, Contact Information, Basic Employment Information

Formal Name:
Preferred/Nickname:
Other names you have worked under (maiden, prior marriage, ect…):

Current Address:

Years at this address:

Mailing Address (if different):

Home Phone: Cell Phone:

Primary Email: Alternate Email:

Are you 18 years of age or older? yesno

How did you learn of this opening? Other:

Are any of your relatives presently employed with us? yesno If yes, which department?

Are you a U.S. citizen? yesno

Have you ever been employed by Pioneers Medical Center? yesno If yes, when?

Consider my application for the following positions:

If you are forwarding this application for consideration when future openings occur, please list the type of positions you would like to be considered for:

Nursing applicants – please indicate clinical preferences:

1.

2.

3.

Desired Work Schedule:

Status: Full TimePart TimeTemporaryPRNAny
Shift: DaysEveningsNightsRotatingWeekendsHolidays
Wage or Salary Requirements:

Employment Experience

How many positions have you held to date?

Most Recent Position

Employer’s Name and Address:

Employer’s Phone Number(s):

Name Appearing in Employer’s Records:

Start Date (Month/Year): Finish Date (Month/Year): [textprevempfin1]

Position Title: Status:

Average number of hours worked per week: Final Salary:

Position Duties and Responsibilities:

Reason for leaving position:

Supervisor’s or Manager’s Name and Phone Number:

May we contact your supervisor or manager? YesNo

Second Most Recent Position

Employer’s Name and Address:

Employer’s Phone Number(s):

Name Appearing in Employer’s Records:

Start Date (Month/Year): Finish Date (Month/Year): [textprevempfin2]

Position Title: Status:

Average number of hours worked per week: Final Salary:

Position Duties and Responsibilities:

Reason for leaving position:

Supervisor’s or Manager’s Name and Phone Number:

May we contact your supervisor or manager? YesNo

Third Most Recent Position

Employer’s Name and Address:

Employer’s Phone Number(s):

Name Appearing in Employer’s Records:

Start Date (Month/Year): Finish Date (Month/Year): [textprevempfin3]

Position Title: Status:

Average number of hours worked per week: Final Salary:

Position Duties and Responsibilities:

Reason for leaving position:

Supervisor’s or Manager’s Name and Phone Number:

May we contact your supervisor or manager? YesNo

Career Highlights

Describe any specialized training (vocational, business, correspondence, etc.), job skills (computer skills, office machine skills, bookkeeping experience, foreign language, etc.), apprenticeships, and/or memberships in professional organizations:

Professional Licenses and/or Registrations Held

Are you professionally licensed or registered with any professional group, association, or society? YesNo
How many professional licenses and/or registrations do you hold?:

Clerical Skills

(Clerical applicants only please complete this section)

Typing WPM: Do you have knowledge of Medical Terminology? YesNo

Education

Provide information about your education, starting with the most recent school attended.

Select the last year of school completed:

High School

Please provide information about the last high school that you attended.

School’s name and address:

Grade Point Average: Graduated: YesNo Graduation Date (Month/Year):

Education Highlights

Describe any honors received, specialized education, skills learned, and extracurricular activities:

Do you plan further education?

Planned course work:

U.S. Military Service

Dates from (Month/Year) to

Branch Present Status

Rank/Grade

List any additional training you received in the military.

Background Check

Have you ever been convicted of an offense greater than a traffic violation? YesNo If yes, explain:

References

Reference Information
(Name, Position or Title, Phone Number, Address, Length of Relationship)

1:

2:

3:

Employment Statements

Pioneers Medical Center is an equal opportunity employer. It is policy that all individuals are entitled to equal employment opportunity regardless of race, color, religion, sex, national origin, age marital status, sexual orientation, ancestry, creed, veteran’s status, or disability, as required by state and federal law. PMC is committed to this policy. All appropriate steps are taken to ensure equal opportunity in employment with respect to all personnel actions, including, but not limited to: recruiting, hiring, compensation, benefits, education and promotion / advancement opportunities.

Applicant’s Statement

I understand employment with Pioneers Medical Center (PMC) is at-will, either party may terminate the employment at any time, with or without cause or prior notice. PMC will not contact my present employer without my permission. I authorize Pioneers Medical Center to investigate other information in this application and to consult with any other individual or organization named in this application. I authorize all named individuals and organizations to provide any information to PMC and I release from liability any individual or organization providing such information.

I further understand if selected for employment, Pioneers Medical Center will be performing background screenings, which may include a criminal background check, credential verification, credit check and/or arrest history record. I further understand PMC will do pre-employment drug testing and may do random drug testing after employment.

I understand that satisfactory completion of a pre-employment health screen, drug screen, and physical therapy/fitness for duty evaluation are conditions of employment. I also understand that refusal to complete the evaluation will preclude my further consideration for employment.

In consideration of any employment resulting from this applications, I agree to comply with all policies and procedures,including PMCs Compliance Program, and I understand that I will be subject to applicable local, state and federal rules,statutes and regulations. I agree to work the hours (including overtime), the days (including weekends and holidays),and the shift (day or night) scheduled by the management of the department in which I am employed.

I understand and agree that if employed, the terms, conditions, and duration of my employment, unless otherwise provided by law, will be determined by the hospital and may be modified from time to time at the discretion of thehospital. I understand Pioneers Medical Center is an at-will employer.

I certify that all information in the application (and accompanying resume, if any) is true and correct and without material omissions. I understand that any incorrect, incomplete, or false information given by me is sufficient cause to void this application and/or terminate my employment.


Applicant’s Confirmation

Yes, I have read and understand the above, and hereby certify that the facts I have provided in my employment application are true and complete. Please submit my application.No, I do not agree with the above Applicant's Statement or the other policies contained in this application. Please cancel my application.