Online Application Position Position(s) you are Applying for? How did you hear about this opening? —Please choose an option—EmployeeAdvertisementLinkedInRecruiterWalk InRelativeOther General Information Full Legal Name Email Address Address Address 2 City State —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip code Phone number Alternate Phone Number Next Assurances Can you present proof of your right to work legally in the United States? —Please choose an option—YesNo Are you at least 18 years of age? —Please choose an option—YesNo On what date would you be able to work: Are you available to work: Full TimePart TimeAs neededEducational co-op Preferred Shift: —Please choose an option—1st2nd3rdAny Wage Type? —Please choose an option—HourlySalary Current Degree: —Please choose an option—High School DiplomaAssociate DegreeBachelor's DegreeMaster's DegreeDoctoral Degree Have you ever filed an application with Paulding County Hospital before? —Please choose an option—YesNo If Yes, date and position Have you ever been employed with Paulding County Hospital before? —Please choose an option—YesNo If Yes, date and position Do you have a valid State of Ohio driver's license? —Please choose an option—YesNo If yes, do you have valid/current vehicle insurance coverage? —Please choose an option—YesNoBackNext Criminal History Have you ever been convicted for something other than a minor traffic violation? —Please choose an option—YesNo What Date Were You Convicted? City of Conviction State —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Type of Conviction Additional Conviction Comments: NOTE: A conviction will not necessarily be a bar to employment. Factors such as age and time of the offense, seriousness, and nature of the violation, and whether the offense is substantially related to the applicant's ability to perform the job applies for and rehabilitation will be taken into consideration. Omission of information is considered falsification of application and if employed will result in termination. BackNext Previous Employment Name of Employer Your Job Title Your Duties Date Started Currently employed? —Please choose an option—YesNo Employed until Pay Rate: Reason for leaving: Supervisor's Name Supervisor's Number May we contact this employer? —Please choose an option—YesNo Previous Employment Name of Employer Your Job Title Your Duties Date Started Employed until Pay Rate: Reason for leaving: Supervisor's Name Supervisor's Number May we contact this employer? —Please choose an option—YesNo Previous Employment Name of Employer Your Job Title Your Duties Date Started Employed until Pay Rate: Reason for leaving: Supervisor's Name Supervisor's Number May we contact this employer? —Please choose an option—YesNoBackNext Education (Most Recent First) Name of School Diploma/Degree and Major/Minor where applicable Completion —Please choose an option—YesNoIn Progress Achievements, Awards, Volunteering and/or Comments Education Name of School Diploma/Degree and Major/Minor where applicable Completion —Please choose an option—YesNoIn Progress Achievements, Awards, Volunteering and/or Comments Education Name of School Diploma/Degree and Major/Minor where applicable Completion —Please choose an option—YesNoIn Progress Achievements, Awards, Volunteering and/or Comments Other Skills & Qualifications List any special training, skills, licenses, and/or certifications that may qualify you as being able to perform job-related functions in the position for which you are applying. BackNext Additional Information List professional, trade, business or civic associations and any offices held*: List special accomplishments, publications, awards, etc*: *Exclude memberships that would reveal sex, race, religion, national origin, age, color, disability or any other similarly protected status. List any other information you would like us to consider: BackNext Reference Full Name Title Company Email Phone Number Address Address 2 City State —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Relationship to Reference Relationship typeProfessionalPersonalBoth Reference Full Name Title Company Email Phone Number Address Address 2 City State —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Relationship to Reference Relationship typeProfessionalPersonalBoth Reference Full Name Title Company Email Phone Number Address Address 2 City State —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Relationship to Reference Relationship typeProfessionalPersonalBoth Family and/or Friends at Paulding County Hospital Do you have any family and/or friends working for Paulding County Hospital? —Please choose an option—NoYes Please provide the name, phone number and relationship to any friends or family members who currently work for Paulding County Hospital. BackNextI understand that if I am employed, any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate discharge from the employer's service, whenever it is discovered. I give the employer the right to contact and obtain information from all references, employers, and educational institutions and to otherwise verify the accuracy of the information contained in the application. I hereby release from liability the employer and its representatives for seeking, gathering and using such information and all other persons, corporations, and organizations for furnishing such information. The employer does not unlawfully discriminate in employment and no questions on this application are used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no representative of the employer, other than an authorized officer, has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by an authorized officer. I understand it is this company's policy not to refuse to hire a qualified individual with a disability because of that person's need for reasonable accommodation as required by the Americans with Disabilities Act (ADA). I understand that if hired, I will be required to provide proof of identity and legal work authorization. I understand that criminal background checks are performed in accordance with state and federal law. I understand that I may be asked to provide fingerprints to perform such a check if I am offered a position. I also understand that if I am extended an offer of employment, I will be required to submit a pre-employment substance abuse test. I further understand that Paulding County Hospital is a drug-free work environment and I can be tested for drugs or alcohol if Paulding County Hospital has reasonable suspicion of me violating this policy. I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions. I agree to the above statement Attach Resume (.doc, .docx, or .pdf) Back
