Application for Employment

Providence Healthcare network will not discriminate against any applicant for employment in regard to race, color, national origin, religion, sex, age or disability in accordance with the provisions of the Civil Right Act of 1964, the Age Discrimination in Employment Act of 1967, Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act and the Civil Rights Act of 1991.

Identification

First Name: *

Middle Initial:

Last Name: *

Business Phone:

Home Phone: *

Social Security #: *

E-mail Address: *

Present Address (Street & Number): *

City: *

State: *

Zip Code: *

Are you either a U.S. citizen or an alien who
has the legal right to work in the job for which
you are applying? *

Visa #:

U.S. Military

Branch of U.S. Service:

Date Entered:

Date Discharged:

Rank at Discharge:

Nature of Duties and Special Training Received:

General

Have you ever been convicted of a crime (felony or misdemeanor)?
Yes... No

If yes, please explain.

Have you ever been excluded from a federal or state health care program (e.g., Medicare) or from a federal procurement or non-procurement program?
Yes... No

If yes, please explain.

Work Experience

Start with your present or last position and work back accounting for all periods of unemployment.

Name of Business (or Company):

Type of Business:

Name and Title of Supervisor:

Address:

City:

State:

Zip Code:

Phone Number:
- -

Started:		Left:		Starting Pay:	Final Pay:
Month	Year	Month	Year	$	$

Job Title and Description of Duties and Responsibilties:

Reason for Leaving:

Name of Business (or Company):

Type of Business:

Name and Title of Supervisor:

Address:

City:

State:

Zip Code:

Phone Number:
- -

Started:		Left:		Starting Pay:	Final Pay:
Month	Year	Month	Year	$	$

Job Title and Description of Duties and Responsibilties:

Reason for Leaving:

Name of Business (or Company):

Type of Business:

Name and Title of Supervisor:

Address:

City:

State:

Zip Code:

Phone Number:
- -

Started:		Left:		Starting Pay:	Final Pay:
Month	Year	Month	Year	$	$

Job Title and Description of Duties and Responsibilties:

Reason for Leaving:

Name of Business (or Company):

Type of Business:

Name and Title of Supervisor:

Address:

City:

State:

Zip Code:

Phone Number:
- -

Started:		Left:		Starting Pay:	Final Pay:
Month	Year	Month	Year	$	$

Job Title and Description of Duties and Responsibilties:

Reason for Leaving:

Name of Business (or Company):

Type of Business:

Name and Title of Supervisor:

Address:

City:

State:

Zip Code:

Phone Number:
- -

Started:		Left:		Starting Pay:	Final Pay:
Month	Year	Month	Year	$	$

Job Title and Description of Duties and Responsibilties:

Reason for Leaving:

Personal References

Name:

Occupation:

Organization:

Address:

City:

State:

Zip Code:

Phone Number:
- -

Name:

Occupation:

Organization:

Address:

City:

State:

Zip Code:

Phone Number:
- -

Résumé

Upload your Résumé

Your document must be in of the following formats: Microsoft Word (.doc), Adobe Acrobat PDF (.pdf), Rich Text Format (.rtf), or Text (.txt).

Additional Information

Public Law 91-508 requires that we advise you that a routine inquiry may be made which will provide information concerning character, reputation, personal characteristics and mode of living. If such inquiry is made, you may obtain additional information as to the nature and scope of the report upon written request.

I certify that the forgoing information is true and correct to the best of my knowledge, and I understand that any misrepresentation or willful omission of facts shall be cause for rejection of this application or termination of employment. I hereby authorize Providence Healthcare Network to conduct work history and personal reference inquiries to determine my acceptability for employment.

I understand and agree that as a condition of employment I will be required to pass scheduled physical examinations. I further agree to observe all rules, regulations and policies of Providence Healthcare Network in a manner compatible with the philosophy and mission of Ascension Health and to abide by the "Ethical and Religious Directives of Catholic Health Facilities."

I understand and agree that drug and alcohol abuse is unacceptable to Providence Healthcare Network due to the sensitive nature of its work and its concern for the well-being of its employees and patients. As a result, I understand and agree that if I am tentatively selected for this position, I will be required to submit to urinalysis to screen for illegal drug use prior to appointment.

I understand and agree that if hired, my employment is for no definite period, regardless of the date of the payment of my wages or salaries, and may be terminated at any time without any prior notice for wages or salary except as may have been earned or through the date of my termination.

Providence Healthcare Network Jobs

Application for Employment

Identification

Job Status

U.S. Military

Education

General

Work Experience

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Personal References

Résumé

Additional Information