Employment Application s20

EMPLOYMENT APPLICATION

POMEGRANATE HEALTH SYSTEMS IS A DRUG FREE WORKPLACE; EMPLOYMENT IS CONTIGENT UPON DRUG SCREEN TEST AND BACKGROUND CRIMINAL INVESTIGATION REPORT.

APPLICANT (Please print clearly and answer all questions completely)

Last Name First Name Middle Initial Alias

Address 21 Years of Age or Older? Yes No

Applicants must be no less than 21 years of age. City State Zip Code Driver’s License State and Number

Contact Phone Number Position Desired Shift Preference Full Time or Part Time

Email Address Salary Desired

Referred By Are you related to a director, officer or employee of Pomegranate? Yes No If “Yes”, state name/relationship: ______

Do you have the legal right to work in this country? Yes No If applicable, Alien Registration Card Number ______

Have you ever been convicted of a felony? Yes No If yes, state details/dates of violation:

______

Have you reviewed the disqualifier list? Yes No (If No – You are required to do so before the interview process.)

I attest that I have not been arrested, indicted, convicted or pleaded guilty of a disqualifying offense. Yes No

If “Yes”, state details/dates of violation:

______

If employed, I agree to notify the company, within 24 hours, if I am charged with, convicted or plead guilty of a disqualifying offense? Yes

Have you ever been suspended and/or excluded from participation in the Federal Medicare or Medicaid program? Yes No

If “Yes”, state reason/dates of suspension or exclusion: ______

If you are or have ever been licensed by a medical, nursing or clinical board, has your license ever been restricted, suspended or revoked? Yes No N/A

If “Yes” state reason/(s)/date(s) of license restrictions, suspension and/or revocation:

______

Have you ever been the subject of an allegation or charge of child abuse or domestic violence? Yes No

If “Yes”, state date, circumstances, nature and outcome of the allegation:

______

MILITARY SERVICE

Have you ever served in the United States Armed Forces? Yes No If “Yes”, which branch? ______

Dates of Service: ______Reserve Status: ______

Special training received: WORK EXPERIENCE Employment History (List all Employers starting with most recent; attach resume or additional pages, if needed) Month/Yr Name of Employer Supervisor Starting and Position(s) Held Reason for Leaving and Complete Name and Ending Salary Address Telephone Number From To

From To

May we contact your current employer? Yes No Please explain all gaps in your employment history. EDUCATION School City and State Dates Attended Degree/Diploma or Major Course(s) of Study GED received High School

College

Additional Training and/or Skill(s)

Professional License(s) Held

PERSONAL REFERENCES Please list at least 3 persons, NOT RELATED TO YOU, who have known you for at least two years and can attest to your character: Name Position and Company Current Address Telephone Number

PLEASE READ AND SIGN BELOW: I hereby authorize all employers for whom I have worked in the past to furnish any information, which Pomegranate Health Systems may request concerning my past employment or activities and I also authorize the solicitation of information concerning my background regarding criminal, driving and general public records. I hereby release all such employers, reporting entities and Pomegranate Health Systems from any liability in connection therewith. I have made true, correct and complete answers and statements on this application in the knowledge that they will be relied upon in considering my application for employment and I understand that any omission, false answer or statement made by me on this application or any supplement to it, will be sufficient grounds for my discharge.

Signed

Applicant Print Name Date

Thank you for applying with Pomegranate Health Systems. Pomegranate Health Systems is an equal opportunity employer and does not unlawfully discriminate against any person or categories of persons who are protected by applicable federal, state or local requirements. We do not unlawfully discriminate in hiring or employment on the basis of race, color, religion, sex, national origin, age, disability, protected activity or other legally protected status. No question on this application or other employment forms is intended to secure information for discriminatory purposes. If you have any questions about this application, please ask a Pomegranate Health Systems Human Resources representative. This application will remain valid for a period of six months. If you have not been offered a position with Pomegranate Health Systems within this time and wish to receive further consideration for employment, you will need to complete another application form.