Henry County Hospital/HCH Diversified Management Corp

1000 N. 16th Street
P.O. Box 490
New Castle, IN 47362
Human Resources/Job Line: (765) 521-1507
Fax: (765) 521-1480

Employment Application

Henry County Hospital/HCH Diversified Management Corp. offers equal employment opportunities to all persons without regard to race, religion, age, sex, color, national origin, ancestry, disability, uniformed service, or other legally protected status. No question on this application is intended to secure information to be used to discriminate on these bases.

Please read carefully and answer all questions. Answer all questions fully, honestly and completely. If a question does not apply to you, print N/A (which means not applicable). Failure to follow these instructions will be considered in making employment decisions. Any false, misleading, or incomplete answers may result in immediate disqualification of consideration for employment or termination of subsequent employment.

The use of this form does not obligate Henry County Hospital/HCH Diversified Management Corp. in any way. Applications will be accepted for current open positions only. We will keep your application on file for one year. However, you must notify Human Resources to be considered for any position other than the one you are applying for at this time or if you have any changes to current information.

Personal Information

Last Name  *
First Name  *
Middle Initial  *
Social Security Number  *
Preferred Name/Nickname
Email Address  *
Current Address  *
City  *
State  *
Zip Code  *
County  *
Home Phone  *
Cell Phone

LIST ALL RELATIVES WHO WORK FOR THE HOSPITAL (NOTE: The employment of a relative is not a qualification for employment and will not result in preference in employment)

Name:
Relation:
Department:

 

Name:
Relation:
Department:

 

Name:
Relation:
Department:

If you are under 18, do you have a work permit? Yes No

Do you have, or will you have at the beginning of your employment (if hired), the legal right to remain and work in the United States? Yes No *

Do you hold a professional registration, license, or certification? Yes No *

If yes, Type(s) State(s) Number(s) Expiration Date(s)

Have you ever been employed by Henry County Hospital/HCH Diversified Management Corp? Yes No *

If yes, From: To: Position: Supervisor:
Reason for leaving:

Have you ever been convicted of or pled guilt or no contest to a felony, misdemeanor or any offense other than a minor traffic violation? (a conviction will not necessarily disqualify you from consideration. However, failure to fully disclose will result in denial or termination of employment) Yes No *

Are any criminal charges now pending against you? Yes No *

Have you ever had any professional registration, license or certification suspended or revoked? Yes No *

Have you ever informally resolved any recommended or potential adverse action involving your professional registration, license or certification? Yes No *

Are any professional registration, licensure or certification actions now pending against you? Yes No *

Has any action been taken against you that excludes or has excluded you from participation in any federal or state government healthcare program, including but not limited to Medicare? Yes No *

Have you ever been named as a defendant in a civil legal action involving your professional competence? Yes No *

If you answered "yes" to any of these questions, please explain:

Position Availability

Position applying for:  *

Shifts you are available to work:
Full-Time
Part-Time
Weekend Option
PRN/Temporary
Summer Help

Date you are available to work:  *

Do you have, or can you obtain, reliable transportation to work? Yes No *

Educational Background

High School

Name, City State: Degree: Years Completed: Major Course of Study:

College

Name, City State: Degree: Years Completed: Major Course of Study:

Name, City State: Degree: Years Completed: Major Course of Study:

Graduate

Name, City State: Degree: Years Completed: Major Course of Study:

Trade, Business, Correspondence, or Vocational

Name, City State: Degree: Years Completed: Major Course of Study:

Military Service

Branch: Rank at Discharge: Dates of Service:

Skills/Experience

Job related skills:
Special skills applicable to job for which you have applied:
Office equipment you operate:

Working knowledge of computer software: Yes No

Competency Level: Beginner Intermediate Advanced

If yes what programs: MS Word MS Excel MS PowerPoint MS Access

Other Software:

Employment History

PLEASE COMPLETE ALL INFORMATION, EVEN IF A RESUME IS ATTACHED. List present or most recent employer first, followed by the previous employers. Give a complete record of all employment and reasons for periods of unemployment during the past 10 years.

Job Details

Employer:  *
City:
State:
Zip:
Employer Phone:
Name of Supervisor:
Dates of Employment: From to
Starting Pay: Ending Pay:
May we contact this employer: Yes No

Job Title/Summarize the nature of the work performed and job responsibilities:
Reason for leaving:

Job Details

Employer:  *
City:
State:
Zip:
Employer Phone:
Name of Supervisor:
Dates of Employment: From to
Starting Pay: Ending Pay:
May we contact this employer: Yes No

Job Title/Summarize the nature of the work performed and job responsibilities:
Reason for leaving:

Job Details

Employer:
City:
State:
Zip:
Employer Phone:
Name of Supervisor:
Dates of Employment: From to
Starting Pay: Ending Pay:
May we contact this employer: Yes No

Job Title/Summarize the nature of the work performed and job responsibilities:
Reason for leaving:

Job Details

Employer:
City:
State:
Zip:
Employer Phone:
Name of Supervisor:
Dates of Employment: From to
Starting Pay: Ending Pay:
May we contact this employer: Yes No

Job Title/Summarize the nature of the work performed and job responsibilities:
Reason for leaving:

References

You must list at least two references (not related to you) that can comment on your work habits, responsibility, character and conduct.

Name: Years known: Phone: Address:  *

Name: Years known: Phone: Address:  *

Name: Years known: Phone: Address:

I hereby voluntarily, in connection with this application, authorize all corporations, companies, educational institutions, persons, police department or law enforcement agencies, military services, former employers and anyone else Henry County Hospital/HCH Diversified Management Corp. deems appropriate to contact with regard to this application to release information they may have about me (including but not limited to information relating to my dates of employment, job titles, employment application, performance evaluations, wage or salary history, disciplinary actions, attendance record, and reason for leaving), to Henry County Hospital/HCH Diversified Management Corp. or its agents, and I release them and Henry County Hospital/HCH Diversified Management Corp. and its agents from any and all liability for disclosing and/or reviewing such information. I understand that any information acquired may be disclosed to supervisory personnel within Henry County Hospital/HCH Diversified Management Corp. and/or others who, in the sole judgment of Henry County Hospital/HCH Diversified Management Corp., may have a legitimate interest in such information.

I understand that nothing contained in this application or in the granting of an interview creates a contract between Henry County Hospital/HCH Diversified Management Corp. and me either for employment or for the providing of any benefits. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon Henry County Hospital/HCH Diversified Management Corp. unless made in writing by the Chief Executive Officer of Henry County Hospital/HCH Diversified Management Corp. I understand that, if I am hired, I will be an at-will employee which means that either I or Henry County Hospital/HCH Diversified Management Corp. has the right to modify the at-will nature of the employment relationship and that such modification, if made, must be in a written document signed by the Chief Executive Officer and I.

I understand that any offer of employment is contingent on the satisfactory results of a pre-employment medical examination, which may include a test to detect the presence of drugs or alcohol. I authorize the release and disclosure of the results of the medical examination to Henry County Hospital/HCH Diversified Management Corp. I understand that the results of the medical examination may be disclosed to supervisory personnel within Henry County Hospital/HCH Diversified Management Corp. and/or others who, in the sole judgment of Henry County Hospital/HCH Diversified Management Corp., may have a legitimate interest in such information.

I hereby certify that all statements made by me on this application are true and complete to the best of my knowledge, and I have withheld nothing that would affect the application unfavorably. I understand that false, misleading or incomplete information given on this application or in any subsequent interview(s) may result in immediate disqualification of consideration for employment or termination of subsequent employment.

I agree to take any pre-employment personality, aptitude, and/or skills tests that may be lawfully required by Henry County Hospital/HCH Diversified Management Corp.

I HAVE CAREFULLY READ OVER THIS ENTIRE APPLICATION FOR EMPLOYMENT AND UNDERSTAND FULLY ALL OF ITS CONTENTS AND INSTRUCTIONS.

MY TYPED NAME SHALL HAVE THE SAME FORCE AND EFFECT AS MY WRITTEN SIGNATURE.

Signature:  * Date:  *

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