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.
Date of Application
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Specific Position Applied For
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Your Full Name
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Current Address
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City
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State
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Zip Code
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Previous Address
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Previous City
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Previous State
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Previous Zip Code
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Social Security Number
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Your Full Name
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Names and Addresses of person(s) to be notified in case of an accident or an emergency.
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Are you presently legally authorized to work in the United States of America on a full-time bases?
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Are you at least 18 years of age, can you furnish a work permit?
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If yes, when and where
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Are you employed now?
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May we contact your present employer?
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If yes, when and where
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Are you available to work
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Have you been convicted of a crime (felony or misdemeanor) during the past seven (7) years?
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Do you have any arrests whose outcomes are still pending?
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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.)
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Special Skills and Qualifications

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

High School
Name and Address of School
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High School Graduated?
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High School Degree or major of study
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Business or Technical School
Name and Address of School
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Business or Technical School Graduated?
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Business or Technical School High School Degree or major of study
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College or University
Name and Address of School
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College or University Graduated?
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College or University Degree or major of study
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Other
Name and Address of School
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Other Graduated?
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Other Degree or major of study
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Certified In:

License Number:

Expiration Date:

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

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

Applicant Signature
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Select a Date
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