Application for Employment

(1)

H

HHAAAMMMIIILLLTTTOOONNN HHHEEEAAALLLTTTHHH CCCEEENNNTTTEEERRR,,, IIINNNCCC... 1 1 0 S 1 7T H

ST R E E T, HA R R I S B U R G, P A 1 7 1 0 4

Application for Employment

An Equal Opportunity Employer

Hamilton Health Center, Inc. is an equal opportunity employer. We consider applicants for all positions without regard to sex, race, color, ancestry, religious creed, national origin, physical disability (including HIV and AIDS), mental disability, medical condition (Cancer), age (over 40), marital status, political affiliation, sexual orientation, disabled veteran or Vietnam era veteran status, or any other characteristic protected by law. Hamilton Health Center, Inc. is a Drug-Free Workplace. We test for the use of illegal drugs on all applicants who have been extended an offer of employment.

Your completed application form will be maintained in our active files for twelve (12) months from the date of the application. Information provided on the application will not be used in any discriminatory manner.

The application must be completed in full even if attaching a resume. Conditions of employment are stated at the end of this form. Please read carefully before you sign this application. The application must be signed by the applicant in ink.

PERSONAL

Please Print Using Ballpoint Pen

Full Name (Last, First, MI) Social Security Number

Position(s) Applied for Date of Application How were you referred to HHC?

Present Address (Street, City, State, Zip) How long?

Previous Address (Street, City, State, Zip) How long?

How may we contact you? Home Phone: Cell Phone: Work Phone: What is your email address?

Are any of your relatives presently employed with Hamilton Health Center? [ ] YES [ ] NO If yes, name of relative:

Have you ever worked for Hamilton Health Center? [ ] YES [ ] NO

(2)

GENERAL INFORMATION

If you are under the age of 18, please state your age: If under age 18, can you supply working papers? [ ] YES [ ]NO

Only U.S. Citizens or Aliens who have a legal right to work in the U.S. are eligible for employment. Can you, upon employment, provide genuine documentation establishing your identity and eligibility to be legally employed in the United State? [ ] YES [ ] NO

If any of your educational or employment records are under another name other than the one provided above, please provide the other name(s).

Have you ever been convicted of a crime or violation other than a minor traffic infraction? [ ] YES [ ] NO

(A conviction record will not necessarily be a bar to employment. Factors such as job relations, age and time of the offense, seriousness and nature of violation and rehabilitation will be taken into account.) If yes, please explain:

Have you ever been discharged from any employment or asked to resign? [ ] YES [ ] NO If yes, please explain:

Please check schedule availability:

[ ] I am available and desire to work FULL-TIME (40 hours) and do not have restrictions on my hours and days. (Complete Section B.)

[ ] I am available and desire to work PART-TIME (If less than 40 hours a week, please complete Sections A & B).

A. I am only available for PART-TIME because:

[ ] Student [ ] Other Job [ ] Other (explain) _________________________

B. Hours available MON TUE WED THUR FRI SAT SUN

From [] A.M. _{[] P.M.} [] A.M. _{[] P.M.} [] A.M. _{[] P.M.} [] A.M. _{[] P.M.} [] A.M. _{[] P.M.} [] A.M. _{[] P.M.} [] A.M. _{[] P.M.} To [] A.M. _{[] P.M.} [] A.M. _{[] P.M.} [] A.M. _{[] P.M.} [] A.M. _{[] P.M.} [] A.M. _{[] P.M.} [] A.M. _{[] P.M.} [] A.M. _{[] P.M.}

NOTE: Work schedules are based upon the needs of the business and may be subject to change on a weekly basis.

Salary or Wage expected: Date available for work?

EMPLOYMENT HISTORY

Begin with your most recent employment [1] and continue with all past employment (Attach additional sheet if necessary)

1

Complete in full, do not indicate reference to attachments

From To

Employer: Salary /Wage:

City, State, Zip: Type of Business:

Phone Number: Name & Title of Immediate Supervisor:

Job Title: Describe your Duties:

(3)

May we contact employer? [ ] Yes [ ] No

2

From To

Reason for Leaving (Please explain)

3

From To

4

From To

(4)

EDUCATION

Education

Type of School Name/Address/Phone - School

Major Subject

Circle last

year attended Graduated Degree High School 9 10 11 12 [ ] YES [ ] NO College 1 2 3 4 [ ] YES [ ] NO College 1 2 3 4 [ ] YES [ ] NO Graduate School 1 2 3 4 [ ] YES [ ] NO Business Trade / Other

1 2 3 4 [ ] YES [ ] NO Business Trade / Other

1 2 3 4 [ ] YES [ ] NO

ADDITIONAL EXPERIENCE OR QUALIFICATIONS

List any other experience, skills or other qualifications including hobbies, which you believe should be considered in evaluating your qualifications for employment. Please indicate any prior military service which you would like us to consider in connection with your application for employment.

Languages you speak or can interpret:

Certifications/Designations/Licenses:

Course: Certification State Expiration Date

Military Record Branch Date of Duty: Rank at Discharge:

ATTENDANCE AND PUNCTUALITY INFORMATION

Consistent attendance and punctuality are essential requirements of every job with this company. Is there anything which would interfere with your regular attendance and punctuality if you are offered a job with the company?

(5)

PERSONAL OR BUSINESS REFERENCES

1

Name Occupation Business Phone

Home Address/ Home Phone Title Relationship

City , State, Zip How Long Known

2

City, State, Zip How Long Known

3

City, State, Zip How Long Known

NOTIFICATION AND AGREEMENT

I hereby certify that the answers and any other information on this application are true and correct and that I understand any misrepresentation or omission of facts on my part will be justification for termination from Hamilton Health Center, Inc., if I am employed.

I hereby authorize Hamilton Health Center, Inc. to investigate my previous record of employment or educational experience to determine any and all information of concern to my record, whether same is of record or not, and I release employers and persons named in my application from all liability for any damages on account of his/her furnishing said information.

I understand that nothing in this application or in the granting of an interview is intended to create a guarantee or employment, or an employment contract between Hamilton Health Center, Inc. and myself for either employment or for the providing of any benefit. If an employment relationship is established, I hereby understand and acknowledge: 1) that any employment relationship with Hamilton Health Center, Inc. is of an “AT-WILL” nature, which means that I have the right to terminate my employment at any time for any reason and that Hamilton Health Center, Inc. retains the same right, and 2) after discussion and reasonable notice, my hours of employment may change, based on the business needs of Hamilton Health Center, Inc.

In the event that I am offered and accept a position with Hamilton Health Center, Inc., I understand that I am expected to comply with Hamilton Health Center, Inc, policies and other communications distributed to all employees. I acknowledge that Hamilton Health Center, Inc. reserves the right to amend or modify the policies in its employee handbook and other policies at any time, for any reason, without prior notice.

In consideration of my being considered for employment and/or being employed, I hereby agree to submit to examinations and tests, including drug and alcohol tests, as may be required by Hamilton Health Center, Inc. I hereby release Hamilton Health Center, Inc., from any liability from its use of these examinations, tests or related reports in connection with my application and/or employment, or with regard to the defense of any legal action or proceeding.

I acknowledge that I have read and understand the above statements and hereby grant permission and confirm the information supplied on this application.

(6)

When returning, please separate

the following two documents from the Application

and send directly to Human Resources



Employment background authorization form

(7)

Notification and Authorization to Conduct Employment Background Investigation

I hereby authorize ADP Screening and Selection Services, an Agent for Hamilton Health Center, Inc. to investigate my background to determine any and all information of concern to my record, whether same is of record or not, and I release employers and persons named in my application from all liability for any damages on account of his/her furnishing said information. I understand that this form indicates that a background search will be conducted and that this is my notification of that intent. I understand that the purpose of this background investigation is to determine my suitability for employment and may elicit information on my character, general reputation, personal characteristics and mode of living.

Additionally, you are hereby authorized to make any investigation of my personal history, educational background, military record, motor vehicle records, and criminal records and credit history through an investigative or credit agency or bureau of your choice. I authorize the release of this information by the appropriate agencies to the investigating service. This authorization, in original or copy form, shall be valid for this initial report only.

PLEASE PRINT CLEARLY

Full Name:

Other Names Used/Dates:

Current Address: Phone___________________

List all Addresses for Past 7 years:

Dates: Dates: Dates:

Social Security # Date of Birth:

Drivers’ License# State Issued:

*** MAY WE CONTACT YOUR CURRENT EMPLOYER? YES _______NO

*** HAVE YOU EVER BEEN CONVICTED OF A CRIME? YES _______NO

(You may omit minor traffic offenses, any convictions which have been sealed, expunged or statutorily eradicated, convictions more than two years old for the following marijuana related offenses: HS11357b&c, HS11360c, HS11364, HS11365, HS11550, and misdemeanors for which probation was completed and the case was judicially dismissed)

If yes, please explain:

____________________________________________________________________________________________________ ____________________________________________________________________________________________________

Note: No applicant will be denied employment solely on the grounds of conviction of a crime. The nature of the

offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position will

be considered.

SIGNATURE(required): DATE:

For California Applicants, under Section 1786.22 of the California Civil Code, you have the right to request from ADP Screening and Selection Services, upon proper identification, the nature and substance of all information in its files on you, including the sources of information, and the recipients of any reports on you which ADP Screening and Selection Services has previously furnished within the two-year period preceding your request. You may view the file maintained on you by ADP Screening and Selection Services during normal business hours. You may also obtain a copy of this file upon submitting proper identification and paying the costs of duplication services. Upon making a written request, you may receive a summary of your report via telephone.

NOTICE: Under federal law, you have the right to request disclosure of the nature and scope of our investigation by providing us with a written request within 60 days of our background investigation.

(8)

APPLICANT DATA RECORD

Applicants are considered for all positions, and employees are treated during employment without regard to sex, race, color, ancestry, religious creed, national origin, physical disability (including HIV and AIDS), mental disability, medical condition (Cancer), age (over 40), marital status, political affiliation, sexual orientation, disabled veteran or Vietnam era veteran status, or any other characteristic protected by law. As an employer/government contractor, we comply with government regulations and affirmative action responsibilities. Solely to help us comply with government recordkeeping, reporting and other legal requirements, please fill out the Applicant Data record. We appreciate your cooperation. Refusal to provide this information will not subject you to adverse treatment.

This data is for periodic government reporting and will be kept in a confidential file separate from the Application for Employment.

Please Print

Position (s) applied for___________________________________Date____________________________ Referral Source:

___Advertisement, ____Friend, ____Relative, ___Walk-in, ____Employment Agency,____Other Name __________________________________________Phone (______) _________________________ Address_______________________________________________________________________________ Gender: ____________________ Male ____________________Female

Check if any of the following are applicable:

_______Vietnam Era veteran ____Disabled veteran _______Disable individual

RACE/ETHNICITY: (Please check one of the descriptions below corresponding to the ethnic group with

which you identify.)

___ Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

___ White (Not Hispanic or Latino) – A person having origins in any of the original peoples of Europe, the Middle East or North Africa.

___ Black or African American (Not Hispanic or Latino) – A person having origins in any of the black racial groups of Africa.

___ Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) – A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands.

___ Asian (Not Hispanic or Latino) – A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.

___ American Indian or Alaska Native (Not Hispanic or Latino) – A person having origins in any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment.