Apex Hospital - Pearland

APEX HOSPITAL - KATY

APEX HOSPITAL - PEARLAND

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Application for Employment

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)

Position(s) Applying For:*	Date of Application (months/day/year)*
	mm dd yy

Current Last Name*	First Name*	Middle Initial*

Street Address*	Apt. No.*	City*	State*	Zip Code*

Telephone Number(s)*	Social Security Number *	Email*

Are you legally eligible for employment in the United States?	Yes No
Are you of legal age to work in the United States?	Yes No
If you are under 18 years of age, can you provide required proof of your eligibility to work?	Yes No
Have you ever filed an application with us before?	Yes No
If Yes, give date:	mm dd yy
Have you ever been employed with us before?	Yes No
If Yes, give date:	mm dd yy
Are you available to work:	FULL TIME PART TIME SHIFT WORK TEMPORARY
Are you currently on “lay-off” status and subject to recall?	Yes No
Can you travel if a job requires it?	Yes No
If so, how far	miles
If No, please explain:
Have you ever been convicted of, or plead guilty or no contest (nolo contendere) to, a felony or are you currently facing a pending felony charge that has not yet been resolved?	Yes No
If yes, please describe the conviction(s) or pending criminal charge(s) in detail, including dates.*

Educational Background

Name and Address of School	Course of Study	Years Completed	Diploma / Degree
Elementary School High School
Undergraduate College
Graduate/ Professional
Other (Specify)

Indicate any foreign languages you can speak, read, and/or write

FLUENT	GOOD	FAIR
SPEAK
READ
WRITE

Describe any specialized training, apprenticeship, skills, and extra-curricular activities you have been involved in:

Describe any job-related training received in the military:

List membership in professional, trade, business, or civic activities and offices held, Exclude memberships which would reveal gender, race, national origin, age, ancestry, sexual orientation, disability, or any oilier protected status):

Employment Experience

Start with your present or most recent job. Include any job-related military service assignments and volunteer activities..
(Exclude employment experiences which would reveal gender; race, national origin, age, ancestry, sexual orientation, disability, or any other protected status)

	DATES EMPLOYED
Employer	From	To
Worked Performed:
Address
Telephone Numbers(s)	HOURLY RATE/SALARY
Job Title	Starting	Final
Reason for Leaving
Supervisor
Place an "X" here if you don’t want us to contact this employer

	DATES EMPLOYED
Employer	From	To
Worked Performed:
Address
Telephone Numbers(s)	HOURLY RATE/SALARY
Job Title	Starting	Final
Reason for Leaving
Supervisor
Place an "X" here if you don’t want us to contact this employer

	DATES EMPLOYED
Employer	From	To
Worked Performed:
Address
Telephone Numbers(s)	HOURLY RATE/SALARY
Job Title	Starting	Final
Reason for Leaving
Supervisor
Place an "X" here if you don’t want us to contact this employer

	DATES EMPLOYED
Employer	From	To
Worked Performed:
Address
Telephone Numbers(s)	HOURLY RATE/SALARY
Job Title	Starting	Final
Reason for Leaving
Supervisor
Place an "X" here if you don’t want us to contact this employer

Professional References

Please provide a list of professional references. (Do not include family members, friends, etc.) A separate reference report is available to document reference information.

Name of Referenced and Job Title
Telephone Number (day)
Telephone Number (alternate)
Address:

Name of Referenced and Job Title
Telephone Number (day)
Telephone Number (alternate)
Address:

Name of Referenced and Job Title
Telephone Number (day)
Telephone Number (alternate)
Address:

Applicant's Statement

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision, including verification of professional license as required and background investigations which may include an examination of educational credentials, criminal convictions, and driving records as required by the responsibilities of the position.

This application for employment shall be considered active for a period of time not to exceed forty five (45) days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will” nature, which means that the employee may resign at any time, and Apex Hospital may discharge the employee at any time with or without cause, It is further understood that this at will” employment relationship may not be changed by any written document, or by conduct, unless such changes are specifically acknowledged in writing by an authorized executive of Apex Hospital.

I also understand that employment with Apex Hospital and its’ subsidiaries or divisions may be contingent upon proof of a physical exam. Additionally, I understand that employment with Apex Hospital will not commence until successful completion of Code of Conduct and HIPAA training and other training modules as required for the position.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in immediate discharge. I understand, also, that l am required to abide by all the rules and regulations set forth by Apex Hospital and its’ subsidiaries and divisions.

I certify that I am not and never have been excluded from any federally funded healthcare program, including Medicare or Medicaid, and, if hired, I agree to immediately disclose any threatened or proposed exclusion. I also understand that I have an affirmative duty to report any investigations by a duly authorized licensing and sanctioning authority.

The undersigned indicates that I have read the job description for the position and can carry out the duties and responsibilities stated therein.

Date (month/day/year)