1941 Virginia Avenue | Connersville, IN 47331 www.fayetteregional.org
Fayette Regional Health System ("FRHS") is an equal opportunity employer. Applicants are considered for employment without regard to race, religion, age, sex, color, national origin, ancestry, citizenship, disability, uniformed service, union bias or any other protected class in full compliance with applicable law. Further, FRHS will reasonably accommodate religious practices and otherwise qualified individuals with known disabilities in full compliance with applicable law.
The use of this form does not mean there are positions open and does not obligate FRHS in any way. Your employment application will be considered active for sixty (60) days. You must reapply if you wish to be considered for employment beyond this period of time.
Note: If you would like to include a resume along with your application, send an email to employment@fayetteregional.org with your resume attached.
How did you hear about employment opportunities with FRHS?
Referred by current employee Newspaper FRHS website CareerBuilder Other
Have you ever applied for employment with FRHS?
yes - approximate date(s): no
Have you ever been employed by FRHS?
yes no If yes, give names under which you were employed and approximate date(s) of employment
yes no
If yes, give names under which you were employed and approximate date(s) of employment
Are you available to work:
Full Time Part-time Temporary PRN (as needed) Overtime On-call Weekends If Part time, specify days and hours
Full Time Part-time Temporary PRN (as needed) Overtime On-call Weekends
If Part time, specify days and hours
Shift Preference:
First (days) Second (evenings) Third (nights) Any
Are there any days/times that you would not be available for work?
On what date would you be available for work?
Can you obtain reliable transportation to work assignments?
Are you on a layoff and subject to recall at another employer?
Are any of your relatives employed by us?
yes - name(s) and department(s)/positions(s) no
Are you legally authorized to work in the United States?
Are you 18 years of age or older?
*Have you ever been convicted of or pled guilty or no contest (nolo contendere) to any crime (“crime” includes, without limitation, any felony or misdemeanor)? (A conviction will not necessarily disqualify you from consideration. However, failure to fully disclose will result in immediate denial or termination of employment)
*Are any criminal charges now pending against you?
*Are you currently the subject of a criminal investigation?
What professional licenses, certifications or registrations do you possess? (Please identify by type, State of issue, number, status (active or inactive), and give date(s) of expiration):
Types States Numbers Expiration Dates
Types
States
Numbers
Expiration Dates
*Have you ever had any professional license, certification or registration revoked, suspended, or restricted in any manner?
*Have you ever personally or informally resolved any recommended or potential adverse action involving your professional license, certification or registration?
*Are any professional licensure, certification or registration actions now pending against you?
*Are you or have you ever been excluded from participation in any government healthcare program, including but not limited to Medicare or Medicaid?
*Have you ever been named as a defendant in a civil legal action involving your professional competence?
If you answered yes to any of the questions beginning with an asterisk (*), please explain below.
College or University:
Name of School City and State Number of Years Compelted Graduated: Yes No Course Pursued/Degrees Granted
Name of School City and State Number of Years Compelted Graduated: Yes No
Course Pursued/Degrees Granted
Business, Trade, Correspondence, Technical or Special School or College:
High School
Junior High/Middle School
Starting with present or most recent employer, please list ALL previous employers. Include self-employment, military service, summer, and part-time jobs of any duration. If you need more space, continue on one or more additional sheets of paper. Please complete all information, even if a resume is attached.
Have you ever worked or gone to school under a different name?
yes no If so, please list all names under which you have gone to school or worked:
If so, please list all names under which you have gone to school or worked:
May we contact each of the employers and military branches identified above?
yes no If not, please identify which ones you do not want us to contact, and explain why you prefer that we not contact that employer or military branch:
If not, please identify which ones you do not want us to contact, and explain why you prefer that we not contact that employer or military branch:
Have you ever been discharged, asked to resign from any position, or resigned from any position while you were under investigation for any reason?
yes no If yes, please identify the employer and explain:
If yes, please identify the employer and explain:
Have you ever been disciplined at a place of employment?
List any special job-related skills and qualifications acquired from education, employment, volunteer work or military service:
List specific skills or office machines, tools, machinery, or other equipment that you are trained on and can operate that will be helpful in performing the responsibilities of the position(s) for which you are applying:
List the name, address and telephone number of three references who are not previous employers and are not related to you who would know your work history, work ethic, etc.
(Please indicate that you have read and understand each paragraph of the Applicant Authorization and Certification by checking the boxes below)
I certify that I completed this application for employment with Fayette Regional Health System (“FRHS”), that all information contained on this application is true and complete to the best of my knowledge, and that I have withheld nothing that would affect this application unfavorably. I understand that false, misleading, or incomplete information provided on this application or during the application process (including but not limited to during any interview) likely will result in my not being considered for employment with FRHS or, if I am already employed, in the termination of my employment with FRHS.
I authorize FRHS and its designees to investigate all information provided on this application and/or during the application process (including but not limited to during any interview), and I release FRHS from any and all liability for obtaining, reviewing or using such information as it deems appropriate, in its sole discretion, for considering my application for employment. I understand that an investigation may be made and information may be obtained through several sources, including but not limited to interviews with personal references and past employers, through a credit check, a criminal history check and/or a driver’s record check. This inquiry may include information as to, among other things, my character, general reputation and personal characteristics, my educational background, and information about my work performance and attendance and workplace conduct.
I hereby voluntarily, in connection with this application, authorize anyone FRHS 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 FRHS or its agents, and I release them from any and all liability for disclosing such information (including but not limited to any liability for damages that may result from their furnishing information about me or any action FRHS takes on the basis of such information).
I understand that, if I am offered a job, as a condition of beginning my employment, I will be required to undergo a physical examination, Mantoux TB test, drug and/or alcohol screens, and I hereby authorize any and all doctors, hospitals, clinics, laboratories and other medical facilities to provide FRHS with any medical information about me that FRHS requests in connection with my application for employment. I understand that a positive result indicating the illegal use of drugs (which includes but is not limited to use of a prescription drug without a prescription) likely will result in the withdrawal of any offer of employment.
I understand that all individuals who are hired must, as a condition of their employment, produce certain documentation to verify their identity and their legal authorization to work in the United States. I understand that any offer of employment to me is contingent upon my ability to produce the required documentation within the time period required by law.
I understand that this application is not, and is not intended to be, a contract of employment and that, if I am employed by FRHS, my employment will be for no fixed period of time and may be terminated at any time by me or by FRHS, with or without cause or notice. I further understand that statements which may be contained in policies, practices, handbooks or other material do not create any guarantee of employment and that FRHS may, within its sole discretion, modify, amend or terminate such policies, practices, benefits plans and/or other programs within the limits and requirements imposed by law. I understand that no representative of FRHS, other than FRHS's President and CEO, has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing and that any such agreement must be in writing to be binding.
I understand that by typing my name below, I am creating a legally binding online signature.
Applicant Signature: Date: