Application for Employment - Providers

Application Data

Referral Source:

Emergency contacts:

Name

Address

Job Data:

Skills:

Computer

Education:

Specialty Board Certification

Medical Staff Appointment

Dates

Staff Appointments Status:

Dates

Staff Appointments Status:

Dates

Staff Appointments Status:

Work Experience:

Military:

Reference

Personal or professional references (other than relatives)

Miscelaneous:

Disclosure Questions:

Please read carefully before submitting

I CERTIFY THAT MY ANSWERS TO THE QUESTIONS ARE TRUE. TO SAFEGUARD THE WELFARE OF MYSELF, MY ASSOCIATES, THE PATIENTS AND THE HOSPITAL, I WILL CONSENT TO ALL PHYSICAL AND OTHER EXAMINATIONS REQUIRED AT ANY TIME BY JOINT TOWNSHIP DISTRICT MEMORIAL HOSPITAL. I UNDERSTAND A CONDITION OF EMPLOYMENT IS THAT I PASS ALL SUBSTANCE ABUSE DRUG/ALCOHOL TESTING. I ALSO UNDERSTAND THAT IS EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE CONSIDERED SUFFICIENT CAUSE FOR DISMISSAL. ADDITIONALLY, I UNDERSTAND THAT EMPLOYMENT AT JOINT TOWNSHIP DISTRICT MEMORIAL HOSPITAL CAN BE TERMINATED AT ANY TIME FOR ANY REASON BY THE EMPLOYEE OR THE HOSPITAL.

I AGREE TO WORK THE HOURS, DAYS AND SHIFTS AS NEEDED OR IN ANOTHER AREA OR CLASSIFICATION IF REQUESTED TO DO SO, AND WILL CONDUCT MYSELF ACCORDING TO THE POLICIES AND REGULATIONS OF THIS HOSPITAL. I UNDERSTAND THAT THIS APPLICATION IS NOT NOR IS IT INTENDED TO BE A CONTRACT OF EMPLOYMENT.

I HAVE AUTHORIZED JOINT TOWNSHIP DISTRICT MEMORIAL HOSPITAL TO INVESTIGATE WITHOUT LIABILITY WHATSOEVER ALL STATEMENTS CONTAINED IN THIS APPLICATION AND CONTACT PREVIOUS EMPLOYERS, PERSONAL AND EDUCATIONAL REFERENCES LISTED IN THIS APPLICATION. I ALSO RELEASE ALL INDIVIDUALS OR ORGANIZATIONS CONTACTED OF ALL LIABILITY WHATSOEVER FOR ISSUING ANY REQUESTED INFORMATION.