APEX HOSPITAL - KATY
APEX HOSPITAL - PEARLAND
 
Home | WhiteBoard | Careers | Contact Us
Locations About Our Hospital Leadership Specialized Programs / Services Community    
Application for Employment
 Click Here to Download Application
 
We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.

INSTRUCTIONS:
Complete all the necessary information. You may be asked to provide additional information
on another form. This application will be kept on file, it is to your advantage to periodically check to keep it current and active. Be sure to sign and date the application.
 
(PLEASE PRINT)
As an Equal Opportunity / Affirmative Action Employer, APEX Hospital L.P. and its affiliates, does not discriminate against applicants or employees because of their age, race, color, religion, national origin, sex, disability or on any other basis prohibited by law including but not limited to disabled veteran and/or veteran of the Vietnam are
For Internal Use Only
 
PERSONAL INFORMATION
Date Social Security Number
Name (Last)  (Middle)  (First) 
Current Address  Phone Number
(  )
City   State  ZIP Code  Country 
Email  
          
POSITION DESIRED
Position Applied For 
 

                                  
                 

Salary Expected
                                       
                                      
(check one)                                      		Date Available to Start


 

Shift Preference

             
Have you ever worked for this Company?
                   		If Yes, When and Where?
Have you ever applied to this Company?
                   		If Yes, When and Where?
Do you have any relatives who work for the Company?
                     		If Yes please identify?

Do you have a valid driver's license (only for jobs where driving
a vehicle is an essential function)?

                     
Have you ever been convicted of or plead guilty or no contest to a crime (felony or misdemeanor) other than a minor traffic violation?   If so, please explain.   For purposes of employment with the Company,  "convictions"  include sentenced to confinement, paid fine,  time serviced, placed on probation (including deferred adjudication) and court-ordered restitution.

                  

If yes, please explain:

How did you hear about us?  
     
     
     
     
Please indicate Employee Name/Other:


WORK AUTHORIZATION
Are you legally authorized to work in the USA?                              
TO COMPLY WITH THE IMMIGRATION REFORM AND CONTROL ACT, IF YOU ARE HIRED, YOU WILL BE REQUIRED TO PROVIDE DOCUMENTS TO ESTABLISH YOUR IDENTITY AND YOUR AUTHORIZATION TO WORK IN THE USA.  SUCH DOCUMENTS WILL BE REQUIRED WITHIN THE FIRST THREE (3) BUSINESS DAYS FOLLOWING YOUR HIRE, OR UPON YOUR FIRST WORK DAY IF YOUR EMPLOYMENT WILL BE LESS THAN THREE (3) DAYS.
RECORD OF EDUCATION
Name and Address of School(s)

Dates Attended

Graduated

Type of
Degree/Diploma
Received or
Expected

Major /
Minor
Fields of
Study

  

From
Optional

To
Optional

Yes

No

  
High School
(last attended)		  
Colleges &
Universities
Graduate
School		  
Other:
Business
Technical
Secretarial
Etc...		  
    
   
 
       
 
 
 
 
 
 
 
 
  
 
PLEASE LIST ANY PROFESSIONAL AFFILIATIONS OR ACCREDITATIONS THAT HAVE A DIRECT
BEARING UPON YOUR QUALIFICATIONS FOR THE JOB FOR WHICH YOU ARE APPLYING.
 

INCLUDE ALL LICENSES AND CERTIFICATIONS:

 

HAVE YOU EVER HAD YOUR PROFESSIONAL LICENSE OR CERTIFICATION SUSPENDED, REVOKED,
OR RESTRICTED?        

                   

IF YES, PLEASE EXPLAIN:

 
DO YOU HAVE ANY SPECIAL SKILLS OR ABILITIES THAT DIRECTLY RELATE TO THE JOB FOR
WHICH YOU ARE APPLYING?
 

PLEASE LIST:

 
WORK EXPERIENCE
(List Most Recent Experience First)
1 Employer Name FROM: (Employment Start Date)

TO: (Employment End Date)

   Starting Position Ending Position
Address Supervisor Name & Title Supervisor Name & Title
City, State ZIP
Beginning
Salary/Wage 		Ending
Salary/Wage
Reason for Leaving:
Phone
       
 Eligible for Rehire? 
  
  MAY WE CONTACT YOUR CURRENT EMPLOYER LISTED ABOVE?                 
2 Employer Name FROM: (Employment Start Date)

TO: (Employment End Date)
 

 

Starting Position


Ending Position
Address Supervisor Name & Title Supervisor Name & Title
City, State ZIP
Beginning
Salary/Wage 		Ending
Salary/Wage

City, State ZIP


Phone
   

Phone

  MAY WE CONTACT YOUR CURRENT EMPLOYER LISTED ABOVE?                 
3
Employer Name
FROM: (Employment Start Date)

TO: (Employment End Date)

 

Starting
 Position


Ending
Position
Address
 Supervisor Name & Title
 Supervisor Name & Title
City, State ZIP
Beginning
Salary/Wage 		Ending
Salary/Wage

City, State ZIP


Phone
   

Phone

  MAY WE CONTACT YOUR CURRENT EMPLOYER LISTED ABOVE?                  
 
Use this space to describe any previous work history and/or detail particular job responsibilities listed above that you believe are important or should be considered. Include any additional information you feel may be relevant to the job for which you are applying.
 
 

This application shall only remain active for 60 days. After 60 days, if you are still interested in employment at this Company, you must fill-out a new application.

I hereby do 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 of employment.

I give the Employer the right to investigate all references, to contact all prior employers and to secure additional information about me, if job related. I hereby release from liability the Employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information. I agree to immediately notify the Company if I am convicted of, receive deferred adjudication in, or otherwise plead guilty or no contest to a felony or any crime involving dishonesty, breach of trust or injury to a person, while my application is pending or during my employment if hired.

REFERENCES (Name, City, State)                                 Phone Number                                                  Reference Type:

1.     (               )                      
2.   (              )                      
3.   (              )                       
4.   (              )                       
 
I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contact between this Company 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 at any time, with or without cause. I understand that if this Company employs me, I will be employed as an employee at will.

I understand that, subject to Employer's obligations under the Americans with Disability Act (ADA), I must meet all the physical standards established by this Company to perform the essential functions of any job for which I am offered employment. I understand that, if offered employment, I might be required as a condition of employment to take a physical examination. I also understand that, subject to Employer's requirements under the ADA, during employment I might from time to time be subjected to physical examinations and/or physical ability test to demonstrate that I can perform the essential functions of my job.

I understand that this Company requires that I take a drug test as a condition of pre-employment and may from time to time require that I take a drug and/or alcohol test as a condition of employment. This Company reserves the right to conduct searches on company property of employees and their personal property for alcohol, drugs, or for property which might belong to this Company. This Company also reserves the right to conduct searches of the company's property, vehicles and/or equipment at any time. A refusal to submit to a company search can subject an employee to employment termination.

This Company is an equal opportunity employer. This Company does not discriminate against applicants or employees because of their age, race, color, religion, national origin, sex, disability or on any other basis prohibited by law including but not limited to disabled veteran and/or veteran of the Vietnam era.

In signing this form, I certify that I understand and have truthfully answered all the questions and statements in this application.

 
 
 
 

                         
Signature of Applicant                                                      Date

 
 

PLEASE RETURN THIS APPLICATION TO
HUMAN RESOURCE DEPARTMENT

 
AUTHORIZATION AND RELEASE FOR BACKGROUND CHECK
 

I, the undersigned consumer, do hereby authorize APEX Hospital L.P. by and through its independent contractor, to procure a consumer report and/or investigative consumer report on me.

These above-mentioned reports may include, but are not limited to, information as to my character, general reputation, personal characteristics, and mode of living, discerned through employment and education verifications; personal references; personal interviews; my personal credit history based on reports from any credit bureau, if applicable; my driving history, including any traffic citations; a Social Security number verification; present and former addresses; criminal and civil history/records; and any other public record.

I understand that I am entitled to a complete and accurate disclosure of the nature and scope of any investigative consumer report of which I am the subject upon my written request to APEX Hospital Human Resource Office, if such is made within a reasonable time after the date hereof.

I would like a copy of my background report: 
             

I authorize any person, business entity, or governmental agency who may have information relevant to the above to disclose the same to

 

APEX Hospital by and through it's independent contractor, including, but not limited to any and all courts, public agencies, law enforcement agencies, and credit bureaus, regardless of whether such person, business entity, or governmental agency compiled the information itself or received it from other sources.

I hereby release APEX Hospital, it's independent contactor, and any and all persons, business entities and governmental agencies, whether public or private, from any and all liability, claims, and/or demands, by me, my heirs, or others making such claim or demand on my behalf, for providing a consumer report and/or investigative consumer report hereby authorized. I understand that this Notice/Authorization and Release form shall remain in effect for the duration of my employment with APEX Hospital.

I give APEX Hospital permission to investigate any incidents of workplace misconduct of which I have been accused for which I am alleged to have been involved during employment with APEX Hospital.

I certify that the information contained on this Notice/Authorization and Release form is true and correct and that my application or employment may be terminated based on any false, omitted, or fraudulent information.

 
PERSONAL INFORMATION
Date Social Security Number
 Date of Birth
(used only to avoid isidentification) 		Gender
    
Name (Last)                                            (First)                   (Middle)
Current Address Phone Number
(    )
City State ZIP     Country 
ADDRESSES FOR THE PAST SEVEN (7) YEARS
City State ZIP County Dates Lived Here
         
From: 
  		To:
       

From: 
 


To:
       
From: 
  		To:
PROFESSIONAL LICENSURE AND/OR CERTIFICATIONS
Current and Previous Professional Licenses or Certifications License/Certification # State Issued Expiration Date
          
       
         
Drivers License Number  State
 
If you answer yes to any of the questions below, please explain on a separate piece of paper. A conviction, pending charge, or deferred judgment will not necessarily disqualify you from employment. Each conviction, pending charge, or deferred judgment will be evaluated on its own merits with respect to time, circumstances, and seriousness in relation to the job applied for. In addition, certain state laws may bar your employment.
 

Have you ever been convicted of or plead guilty or no contest to a crime (felony or misdemeanor) other than a minor traffic violation? If so, please explain. For purposes of employment with this Company, "convictions" include sentenced to confinement, paid fine, time served, placed on probation (including deferred adjudication) and court-ordered restitution.            

I

Is there a pending criminal charge against you or are you currently under investigation?           

Is there a deferred criminal judgment against you? 
     

Have you ever been sanctioned, disciplined, debarred and/or excluded by a duly authorized regulatory agency, or are there any current restrictions or limits on your license(s) or certification(s)?          

 

Signature                Date : 

 
SUBSTANCE ABUSE AND TESTING POLICY
ACKNOWLEDGEMENT AND CONSENT
 

I. AGREE TO BE BOUND BY POLICY
I do hereby agree to be bound by APEX Hospital, L.P. (the "Company") Substance Abuse and Testing Policy (the "Policy"), the terms of which are incorporated here in by reference, as a condition for employment and for purposes of applying for, accepting, or continuing employment with APEX Hospital, L.P..

II. DRUG FREE STATEMENT
I also hereby state that I am not a user of controlled substances, which have not been prescribed for me by a licensed physician for authorized use. I agree to comply with the Drug-Free Workplace Act provisions under the Company's Substance Abuse and Testing Policy and understand that, as a condition of employment, I must notify the Company if I am convicted of a criminal drug offense occurring in and/or outside the workplace no later than five (5) days after any such conviction.

III. HOLD HARMLESS PROVISION
I hereby agree to furnish a specimen, as required or requested, for testing under the Policy. I also agree that any Company employee who has been authorized and designated by the company for such purposes, or any physician, laboratory, hospital, or medical professional that has been authorized and designated by the Company for such purposes, may perform appropriate chemical tests on my specimen for the presence of illegal drugs or prescription drugs for which I do not have a valid prescription. I further acknowledge that my application for employment or my continued employment with the Company may be affected consistent with the terms of the Policy based upon a positive result of any such test showing substance usage in violation of the Policy.

To the full extent authorized by applicable laws, rules, and regulations, I release and hold the Company, any such designated person or institution identified above, any laboratory utilized under the Policy, their respective employees, agents, and other contractors for services under the Policy, harmless from any liability (including any liability arising by virtue of negligence) arising from any request made to furnish any required specimen for testing, the testing of such specimen pursuant to the Policy, the release of information in accordance with this authorization and any decisions made concerning my application for employment or my continued employment with the Company based upon a positive result of such test showing drug usage in violation of the Policy.

IV. CONSENT TO THE RELEASE OF TEST RESULTS
I hereby give my permission to any Company employee who has been authorized and designated by the Company for such purposes, and any physician, laboratory, hospital or medical professional that has been authorized and designated by the Company for such purposes, to release the results of any tests made pursuant to the Policy to the Company, the Company's designated Medical Review officer, the Company's Workers' Compensation insurance carrier, and any other person who has a lawful right or need to be informed of such results.

In the event I am seriously injured in a work related accident and unable to provide a specimen at that time, I do hereby authorize the Company to obtain, and the treating facility to release, any hospital reports, other documents or specimens which would indicate whether or not there were any controlled substances or alcohol in my system at the time of the accident.

The undersigned further states that he or she has read the provisions of the policy and the foregoing acknowledgement and consent form, or had such documents read to him or her, knows the content thereof and has freely and voluntarily affixed his or her signature on this document.

I hereby freely and voluntarily agree to the terms of this Substance Abuse Policy Acknowledgment and Consent Form.

 
           

This Hospital performs:


 

 

 

The above are the primary reasons for drug testing, but we reserve the right to test for other justified reasons.

Applicant / Employee Name                 (Please Print Name) Social Security Number
   
 
Applicant / Employee Signature Date
   
 

Witness Signature
 Date
 
APPLICANT DATA RECORD
 

It is our policy to provide equal employment opportunity to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, handicap, or veteran status.

VARIOUS AGENCIES OF THE U.S. GOVERNMENT REQUIRE EMPLOYERS TO COLLECT INFORMATION ON APPLICANTS/EMPLOYEES. INFORMATION REQUESTED ON THIS FORM IS FOR PURPOSES OF COMPLIANCE WITH THESE RECORD KEEPING REQUIREMENTS AND TO DETERMINE RECRUITING AND EMPLOYMENT PATTERNS. Such information will in no way affect the decision regarding your application for employment. This form will be kept confidential and maintained separately from your application form.

Completion of this form is voluntary and not required for employment.

 

Name:

 Date:

Position Applied For: