Application of Employment

As an EQUAL EMPLOYMENT OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYEE, Specialty Hospital of Lorain does not discriminate against applicants or employees because of their age, race, color, religion, national origin, sex (except where sex is a bona-fide occupational qualification) or on any other basis prohibited by law. Furthermore, Specialty Hospital of Lorain will not discriminate against any applicant or employee because he or she is mentally or physically disabled, a disabled veteran, or a veteran of the Vietnam era, provided he or she is qualified and meets the requirements established by Specialty Hospital of Lorain for the job.
Field is required!
Field is required!
Date of Application
Field is required!
Field is required!
Specific Position Applied For
Field is required!
Field is required!
Field is required!
Field is required!
Your Full Name
Field is required!
Field is required!
Current Address
Field is required!
Field is required!
City
Field is required!
Field is required!
Home Phone
Field is required!
Field is required!
State
Field is required!
Field is required!
Cell Phone
Field is required!
Field is required!
Zip Code
Field is required!
Field is required!
Email
Field is required!
Field is required!
Previous Address
Field is required!
Field is required!
Previous City
Field is required!
Field is required!
Previous State
Field is required!
Field is required!
Previous Zip Code
Field is required!
Field is required!
Social Security Number
Field is required!
Field is required!
Your Full Name
Field is required!
Field is required!
Names and Addresses of person(s) to be notified in case of an accident or an emergency.
Field is required!
Field is required!
Are you presently legally authorized to work in the United States of America on a full-time bases?
Field is required!
Field is required!
Are you at least 18 years of age, can you furnish a work permit?
Field is required!
Field is required!
Have you ever been employed by Specialty Hospital of Lorain before?
Field is required!
Field is required!
If yes, when and where
Field is required!
Field is required!
Are you employed now?
Field is required!
Field is required!
May we contact your present employer?
Field is required!
Field is required!
If yes, when and where
Field is required!
Field is required!
Are you available to work
Field is required!
Field is required!
Have you been convicted of a crime (felony or misdemeanor) during the past seven (7) years?
Field is required!
Field is required!
Do you have any arrests whose outcomes are still pending?
Field is required!
Field is required!
Felony or Misdemeanor Please Explain:
(A “yes” answer to either of the previous two questions will not necessarily disqualify you for employment. A conviction or pending arrest will be considered only as it is relevant and/or related to the job in question and will therefore require further investigation and more in depth discussion before an employment decision can be reached.)
Field is required!
Field is required!

Special Skills and Qualifications

Summarize special skills and qualifications acquired from previous employment or other life experiences:
Field is required!
Field is required!
Is there any other pertinent (job-related) information that will help us evaluate you for the job you are seeking?
Field is required!
Field is required!
Give name, address and telephone number of two references who are not related to you and are not previous employer:
Field is required!
Field is required!

Education

High School
Name and Address of School
Field is required!
Field is required!
High School Graduated?
Field is required!
Field is required!
High School Degree or major of study
Field is required!
Field is required!
Business or Technical School
Name and Address of School
Field is required!
Field is required!
Business or Technical School Graduated?
Field is required!
Field is required!
Business or Technical School High School Degree or major of study
Field is required!
Field is required!
College or University
Name and Address of School
Field is required!
Field is required!
College or University Graduated?
Field is required!
Field is required!
College or University Degree or major of study
Field is required!
Field is required!
Other
Name and Address of School
Field is required!
Field is required!
Other Graduated?
Field is required!
Field is required!
Other Degree or major of study
Field is required!
Field is required!

Certified In:

License Number:

Expiration Date:

CPR?
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
ACLS?
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Current Employment Experience
Past Employment Experience 1
Past Employment Experience 2
Employer
Present or Most Recent
Field is required!
Field is required!
Type of Business
Field is required!
Field is required!
Address
Field is required!
Field is required!
Starting Date (Month/Year)
Field is required!
Field is required!
Starting Salary
Field is required!
Field is required!
Starting Position
Field is required!
Field is required!
Leaving Date (Month/Year)
Field is required!
Field is required!
Salary on Leaving
Field is required!
Field is required!
Position on Leaving
Field is required!
Field is required!
Name and Title of Supervisor (Present or Last)
Field is required!
Field is required!
Phone Number:
Field is required!
Field is required!
Job Description and Responsibilities
Field is required!
Field is required!
Past Employment Experience
Field is required!
Field is required!
Employer
Field is required!
Field is required!
Type of Business
Field is required!
Field is required!
Address
Field is required!
Field is required!
Starting Date (Month/Year)
Field is required!
Field is required!
Starting Salary
Field is required!
Field is required!
Starting Position
Field is required!
Field is required!
Leaving Date (Month/Year)
Field is required!
Field is required!
Salary on Leaving
Field is required!
Field is required!
Position on Leaving
Field is required!
Field is required!
Name and Title of Supervisor (Present or Last)
Field is required!
Field is required!
Phone Number:
Field is required!
Field is required!
Job Description and Responsibilities
Field is required!
Field is required!
Past Employment Experience
Field is required!
Field is required!
Employer
Field is required!
Field is required!
Type of Business
Field is required!
Field is required!
Address
Field is required!
Field is required!
Starting Date (Month/Year)
Field is required!
Field is required!
Starting Salary
Field is required!
Field is required!
Starting Position
Field is required!
Field is required!
Leaving Date (Month/Year)
Field is required!
Field is required!
Salary on Leaving
Field is required!
Field is required!
Position on Leaving
Field is required!
Field is required!
Name and Title of Supervisor (Present or Last)
Field is required!
Field is required!
Phone Number:
Field is required!
Field is required!
Job Description and Responsibilities
Field is required!
Field is required!
Past Employment Experience
Field is required!
Field is required!

Special Employment Notice to Disabled Veteran, Vietnam Era Veterans, and Individuals with Physical or Mental Disabilities.

Government contractors are subject to 38 USC 2012 of the Vietnam Era Veterans Readjustment Act of 1974 which requires that they take affirmative action to employ and advance in employment qualified disabled veterans and veterans of the Vietnam Era, and Section 503 of the Rehabilitation Act of 1973, as amended, which requires government contractors to take affirmative action to employ and advance in employment qualified disabled individuals.

If you are a disabled veteran, or have a physical or mental disability, you are invited to volunteer this information. The purpose is to provide information regarding proper placement and appropriate accommodation to enable you to perform the job to the best of your ability in a proper and safe manner. This information will be treated as confidential. Failure to provide information will not jeopardize or adversely affect your consideration for employment.

Field is required!
Field is required!
If you wish to be identified, please sign below.
Field is required!
Field is required!
Signed:
Your Full Name Here
Field is required!
Field is required!

This application shall only remain active for 60 days. After 60 days, if you are still interest in employment at the Specialty Hospital of Lorain, you must fill out a new application.

I hereby certify that all statements made in this application are true and correct to the best of my knowledge and belief. I understand and agree that any misrepresentation or omission of facts in my application may be justification for refusal to hire, or termination or employment.

I further understand that an investigative report may be made as to my character and general reputation. I authorize all past employers, schools, persons and organizations having relevant information or knowledge to provide it to Specialty Hospital of Lorain or its duly authorized representatives for its use in deciding whether or not to offer me employment and specifically waive any liability in responding to inquiries in connection with my application. Upon written request by me, within a reasonable period of time, Specialty Hospital of Lorain will make available to me the nature and scope of all reports of every type obtained.

I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Specialty Hospital of Lorain, its subsidiaries and affiliates, and me for either employment or for the providing of any benefit. If I am offered and accept employment, I understand that the employment is for no definite period of time and may, regardless of the date and payment of my wages and/or salary be terminated by either party for any legal reason.

I understand that any employment offer is contingent upon my passing a urine drug test.

In signing this form, I certify that I understand all the questions and statements in this application.

Field is required!
Field is required!
Applicant Signature
Field is required!
Field is required!
Select a Date
Field is required!
Field is required!
Submit