Job Application

This application form is intended for use in evaluating your qualifications for employment. Please answer questions completely and accurately, and sign where indicated. False or misleading statements during the interview and on this form are grounds for terminating the application process, or, if discovered after employment, terminating employment. All qualified applicants will receive consideration without discrimination based on age, race, marital status, sex, nationality, religion, sexual orientation, or disabilities.

Houlton Regional Hospital (“HRH”) is an Equal Opportunity Employer.  HRH offers equal employment opportunity to all qualified applicants for employment and all employees regardless of age, race, color, sex, pregnancy, ancestry, national origin, religion, sexual orientation, gender identity, physical or mental disability, protected whistleblower activity, previous assertion of workers’ compensation claim, genetic information, veteran status, military service, application for military service, or any other status protected by applicable law.  An applicant who does not meet the minimum qualifications of the position(s) for which the applicant applies will not be considered for employment.  If you wish to request a reasonable accommodation to complete this application, interview for the position, or otherwise participate in the hiring process, please notify us.  We will consider all such requests on a case-by-case basis and in accordance with applicable law.

ONLY FOR POSITIONS REQUIRING APPLICANTS TO DRIVE HOSPITAL VEHICLES.

Training

Name
Name
Name and Location
Name and Location

Employment

Please Include Name, Address Occupation
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.