Job Application - Houlton Regional Hospital

Name *

First

Last

Include Middle Initial With First name

Email *

Phone

Mailing address

Address Line 1

Address Line 2

City

State

Zip Code

Physical address (If different)

Address Line 1

Address Line 2

City

State

Zip Code

Position(s) applying for

Job Posting # (s)

Date available

Are you legally authorized to work in the United States?

Yes
No

If you are hired, will you be able to submit proof of the above?

Yes
No

Have you ever been employed by HRH?

Yes
No

If yes, when?

Under what name?

Do you have any relatives employed at HRH?

Yes
No

Their name, HRH Dept and relationship.

Additional name (if more than one relative) , HRH Dept and relationship.

Do you have a current, valid driver’s license?

Yes
No

ONLY FOR POSITIONS REQUIRING APPLICANTS TO DRIVE HOSPITAL VEHICLES.

Have you ever been employed by the Maine Department of Human Services? *

Yes
No

If yes, provide dates, office location and position held:

Have you ever been excluded or sanctioned by the Medicaid and/or Medicare program and/or any other payor? *

Yes
No

If yes, provide details, dates, etc. :

Training

EDUCATION: High School

Name

Location of HS

Did you graduate?

Yes
No

EDUCATION: College/University

Name

Location of College or University

Did you graduate?

Yes
No

List Diploma or Degree

EDUCATION: (Specialized Training/Trade School)

Name and Location

Location of Institution

Did you graduate?

Yes
No

List Diploma or Degree

EDUCATION: Other

Name and Location

Did you graduate?

Yes
No

List Diploma or Degree

LICENSURE TYPE:

State of Issue, Number, and Expiration Date

ADDITIONAL LICENSURE TYPE:

State of Issue, Number, and Expiration Date

Has your professional license ever been suspended or revoked? *

Yes
No

If yes, please specify.

FOR RN & LPN APPLICANTS ONLY: Please check areas in which you have previous experience:

Employment

WORK HISTORY: List Previous Employers, Most Recent First

Dates Employed

Employers Address

Employers Phone

Job Title and Reason for Leaving

WORK HISTORY: Previous Employer

Dates Employed

Employers Address

Employers Phone

Job Title and Reason for Leaving

WORK HISTORY: Any Additional Employer and Dates Employed

Employers Address

Employers Phone

Job Title and Reason for Leaving

What are your salary expectations?

May we contact your current employer?

Yes
No

If no, explain:

PROFESSIONAL REFERENCES (Students please include academic/clinical references) *

Please Include Name, Address Occupation

ANY ADDITIONAL REFERENCES (Students please include academic/clinical references) (copy) *

Please Include Name, Address Occupation

APPLICANT CERTIFICATION

I hereby certify and affirm that the information provided in connection with the application process, including the information on this application, is true, accurate, and complete and that I have not withheld any information that would, if disclosed, affect this application unfavorably. I understand that any omission, falsification, or misrepresentation in connection with this application process, regardless of when or how discovered, may be grounds for rejection of my application, or if after employment commences, immediate termination. I understand that failure to complete this application for employment may result in my disqualification from eligibility for employment. I authorize Houlton Regional Hospital (“HRH”) to investigate all information related to my application in order to determine my qualifications for employment and I understand that such investigations may include contacting any of my former employers and/or current employers (if applicable) or any person, entity, or educational organizations listed on this application. I hereby authorize all persons and entities having information relevant to my application to provide that information to HRH upon request. I expressly release and agree to hold harmless HRH, its employees and agents, and all those providing information to HRH from any liability arising out of or as a result of the request for, provision of, or use of such information. I understand that any offer of employment may be rescinded or my employment terminated if my references are inadequate or unacceptable to HRH or if l violate any of the provisions of this certification. I also understand that any offer of employment may be conditioned upon the satisfactory completion of a pre-placement physical examination and ergonomic review, a medical history examination and related form (depending on the job-relatedness and business necessity), and background checks, including but not limited to, a criminal record check and a motor vehicle records check, as determined in the sole discretion of HRH, in accordance with HRH policies. I understand that information, data, and records provided or disclosed by or on behalf of HRH or that I otherwise learn in the course of dealing with HRH shall be deemed confidential and/or proprietary information. I understand that no right or license, either expressed or implied, is granted to use or disseminate any confidential and/or proprietary information. I have carefully read the above certification and I understand and agree to its terms.