* Name
* Present Address
* City
* State
* Zip
* Home/Nearest Phone
* Social Security No.

* Are you at least 18 years of age? Yes No
(Employment is subject to verification of minimum legal age.)

* Can you produce documented proof of your identity and eligibility for employment in the United States?
Yes No
(Examples: driver’s license, Social Security card, birth certificate, and/or Immigration and Naturalization Service Documents)

Emergency Contact Information

* Name
* Phone Number

Please give previous address, if current address is less than one year old

How soon could you report to work?

Rate of pay Expected

Elementary/Middle School
Address
City
Last Completed Year      5   6   7   8
Did you graduate                     Yes No

High School
Address
City
Last Completed Year    9 10 11 12
Did you graduate                     Yes No

College
Address
Courses Majored In
Last Completed Year       1   2   3   4
Did you graduate                     Yes No
Degree

Post Graduate College
Address
Courses Majored In
Last Completed Year   
Did you graduate                     Yes No
Degree

Present/Last Employer
Address
City
State
May we Contact?                      Yes No
Name Under Which Employed
Employer's Phone
Start Date                      Month    /     Year   
    
Leaving Date                      Month    /     Year   
    
Full Time   Part Time   Temporary
Starting Salary
Final Salary
Starting Position
Job Title
Supervisor's Name & Title
Reason for Leaving

Employer
Address
City
State
May we Contact?                      Yes No
Name Under Which Employed
Employer's Phone
Start Date                      Month    /     Year   
    
Leaving Date                      Month    /     Year   
    
Full Time   Part Time   Temporary
Starting Salary
Final Salary
Starting Position
Job Title
Supervisor's Name & Title
Reason for Leaving

Employer
Address
City
State
May we Contact?                      Yes No
Name Under Which Employed
Employer's Phone
Start Date                      Month    /     Year   
    
Leaving Date                      Month    /     Year   
    
Full Time   Part Time   Temporary
Starting Salary
Final Salary
Starting Position
Job Title
Supervisor's Name & Title
Reason for Leaving

Employer
Address
City
State
May we Contact?                      Yes No
Name Under Which Employed
Employer's Phone
Start Date                      Month    /     Year   
    
Leaving Date                      Month    /     Year   
    
Full Time   Part Time   Temporary
Starting Salary
Final Salary
Starting Position
Job Title
Supervisor's Name & Title
Reason for Leaving

Have you applied for a job with us before?                              Yes No
Have you ever worked for us before?                              Yes No

How did you come to apply?                 Employee Referral
Former Employee
High School Recruitment
College Recruitment
Newspaper Ad
Walk-In
Other   

Have you ever been bonded?                               Yes No
Have you ever been refused a bond?                               Yes No
If yes, state reason and date:       

Have you ever been convicted of a violation of the law execpt a minor traffic violation?                              Yes No
If yes, state date, court, and place where offense occurred.        
(A conviction will not necessarily disqualify you from employment.)

Have you ever been discharged or requested to resign from a position?                               Yes No
Are you employed now?                               Yes No
If yes, may we contact your present employer?                               Yes No

Have you ever held a position of trust (handling money or confidential material?)                              Yes No
If yes, briefly describe:       

Do you have any reason to believe that you would have difficulty meeting this hospital’s work schedules?                  Yes No

Job Applicant’s Agreement and Certification

“I certify that the information given by me in this application is true in all respects, and I agree that if the
information given is found to be false in any way, it shall be considered sufficient cause for denial of employment
or discharge. I authorize the use of any information in this application to verify my statements, and I authorize past
employers, all references, and any other persons to answer all questions asked concerning my ability, character,
reputation, and previous employment record. I release all such persons from any liability or damages on account of
having furnished such information.”

“I understand that nothing contained in this employment application or in the granting of an interview is intended to
create an employment contract between the hospital and myself for either employment or for the providing of any
benefit. No promises regarding employment have been made to me, and I understand that no such promise or
guarantee is binding upon the hospital unless made in writing. If an employment relationship is established, I
understand that I have the right to terminate my employment at any time and that the hospital retains the same
right.”

“If I am offered employment, I agree to submit to a physical examination whenever requested, and I understand my
becoming employed and/or my continued employment are subject to the results of any physical examination related
to my job duties in accordance with hospital policies and procedures.”

“I understand that if employed, policies, and rules which are issued are not conditions of employment and that the
employer may revise policies or procedures in whole or in part, at any time.”

“I understand that this application will be kept on active file for ____ days from the date completed, after which
time I would have to reapply in accordance with established hospital procedures.”

I am also making a personal commitment to uphold the following standards and agree to represent Hardin Medical Center in:

Attitude:  I will project a positive and enthusiastic attitude about my work to co-workers and customers alike. I will make the effort to be helpful, considerate, cheerful, respectful, empathetic, confidential, and supportive in my daily interactions. I will go the extra mile and treat everyone as if he or she is most important.

Appearance:  I will present a professional appearance in my dress and actions because my personal appearance represents Hardin Medical Center.  Therefore, I will practice good personal hygiene, follow the dress code policy, and remember to wear the proper uniform/clothing, sensible jewelry and scents.  I will wear my photo identification badge on the upper half of my body and clearly visible to others.

Sense of Ownership:  I will focus on quality in all interactions and actions as my workday progresses.  I will take pride in whatever I do and be responsible for the outcome of my efforts.  I will focus on building a positive culture and adhere to organizational and departmental policies and procedures. I realize that my work reflects and defines “Sense of Ownership”.

Commitment to Co-Workers:  I will show mutual respect to my co-workers as we work together to serve our customers.  I will recognize and appreciate each person’s role and express gratitude when appropriate. I will work when scheduled, (calling in only when extremely necessary), and not allow personal problems to interfere with my work.  I will follow the “Golden Rule” and treat others as I would like to be treated.

Customer Satisfaction:  I will treat my customers with courtesy and respect.  I will practice AIDET when interacting with customers; anticipate customer needs and respond in a timely and efficient manner; Apologize, Correct, and Take action when customer expectations are not met, and render services without bias. 

Campus Etiquette:  I will practice good manners at all times to create a favorable impression with our customers. I will observe HMC’s tobacco-free campus policy, practice appropriate elevator etiquette, and demonstrate courtesy and accommodate others while using parking areas.

Privacy:  I will do my part in creating and maintaining a safe and trusting environment for our customers. I will ensure that information about our customers is kept strictly confidential and not compromised, conduct all customer assessments and interviews in private, and limit access to customer information to a “need to know” basis.

Safety:  Safety is the responsibility of each HMC employee. Therefore, I will perform my job safely by practicing medical safety, environmental safety, and personal safety.  I will learn the risks and how to avoid them. 

Communication:  I will listen attentively to my customers, so that I can fully understand their needs.  I will pay close attention to both my verbal and non-verbal communications and deliver my messages with courtesy, clarity and care. If I’m unable to answer questions I will find someone who can.  I will greet everyone with a friendly smile and make eye contact, even when passing in the hall. I will practice telephone etiquette at all times.

I have read and I understand the standards of Hardin Medical Center as outlined in the SPICE Standards of Conduct. 

* (Signature of Applicant)                                           

* (Date)