Career Application Step 1 of 7 14% Code of Commitment Dear Applicant, Prior to completing an application for consideration of employment, you must review and agree to adhere to the Hillsdale Hospital Code of Commitment encompassing: professionalism, customer services, quality and teamwork. Professionalism I recognize that I will be the reputation of Hillsdale Hospital and therefore will exhibit professionalism in my appearance, communication, phone etiquette, behavior Customer Service I recognize my treatment of patients and visitors will determine the success or failure of Hillsdale Hospital and I will therefore exhibit courtesy, gratitude, offering respect and privacy for our patients and their families and will provide service recovery when a member of our team does not provide excellent customer service. Quality As a member of Hillsdale Hospital, I will provide the highest level of quality through demonstrating integrity and personal accountability for the care I give, demonstrate compassion to every person I meet on our campus, and promote the health and safety of patients and their families. Teamwork I recognize that every employee and contracted service of Hillsdale Hospital makes a valuable contribution to the patient experience and as such I will demonstrate positive and upbeat communication with the team I am assigned to work. I will remain accountable for my actions to co-workers and will treat patient and employee information confidentially. I will ensure that all patients receive a warm and friendly handoff to another co-worker so that care is uninterrupted. I understand that I am Hillsdale Hospital and because of the care I give, the attention that I pay and the attitude I exhibit, Hillsdale Hospital will remain the best place for providing excellent health care services. I understand it is my responsibility to know and adhere to these established standards of behavior should I become a member of the Hillsdale Hospital Team.Consent* I agree. Applications must be filled out completely. Incomplete applications will not be considered, and an attached resume will not substitute for a complete application. Hillsdale Hospital is proud of its professional image and appearance. Tobacco use is inconsistent with our healthcare philosophy and image. If you use tobacco, we respectfully ask that you not continue with the application process. We thank you for your compliance. Hillsdale Hospital offers equal employment opportunities to all persons without regard to race, religion, age, sex, color, national origin, ancestry, marital status, disability, uniformed service, union membership, weight, height, genetic information, or other legally protected status. No question on this application is intended to secure information to be used for such discrimination. This application will be given every consideration for the position to which the applicant has applied; however, completion of the application does not imply that the applicant will be interviewed or employed, nor does it constitute a contract between Hillsdale Hospital and applicant either for employment or the provision of any other benefit. Applications will remain active for a period of one year after which the applicant must reapply.Personal InformationDate Available* Date Format: MM slash DD slash YYYY Name* First Middle Last Previous Last NamesPresent Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Permanent Address(Enter only If different than present address) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Phone*If you cannot be reached at the above phone number, where may we contact you?Alternate Contact Name First Last Alternate Contact PhoneAre you legally eligible to work in the United States?*YesNoAre you 18 years of age or older?*YesNoAre you a previous employee of Hillsdale Hospital?*YesNoIf so, please indicate approximate dates:*Are you a smoker?*YesNoDate quit? Date Format: MM slash DD slash YYYY Do you use tobacco or other nicotine products?*(i.e., chewing tobacco or other nicotine patches, gum and/or lozenges)YesNoDo you have a visible tattoo?*YesNoIs it visible under standard work attire?*YesNoEmployment InformationPosition(s) You're Applying For*Registered Nurse | Full-Time (Days) | Med SurgRegistered Nurse | Full-Time (Nights) | Med SurgRegistered Nurse | Full-Time (Days) | CCURegistered Nurse | Full-Time (Nights) | CCURegistered Nurse | Full-Time (Days) | Emergency DepartmentRegistered Nurse | Full-Time (Days) | Emergency DepartmentRegistered Nurse | Full-Time | Home CareRegistered Nurse | Full-time | Surgery DepartmentRegistered Nurse / LPN | Full-Time | Skilled Nursing FacilityNursing Assistant | Full-Time | Med SurgRegistered Nurse | Casual | Obstetrics DepartmentRegistered Respiratory Therapist | Full-time | CardiopulmonaryRegistered Respiratory Therapist | Casual | CardiopulmonaryPhysician or Advanced Practice Provider | Full-Time, Part-Time, CasualNursing Assistant | Full-Time | Skilled Nursing FacilityNursing Assistant | Full-Time | Skilled Nursing FacilityNursing Assistant | Full-Time | Med SurgSocial Worker | Full-Time | Behavioral Health UnitSurgical Technologist | Full-Time | Surgery DepartmentPhlebotomist | Full-Time | LaboratoryPhlebotomist | Casual | LaboratoryMedical Assistant | Casual | ClinicsDietary Aide | Full-time |DietaryDietary Aide | Casual | Dietary DepartmentWage Expectations*Will you accept another position?*YesNoIf so, what?Are you available to work weekends?*YesNoAre you available to work holidays?*YesNoAre you available to work rotating shifts?*YesNoAre there any days or hours you cannot work?Will you accept full time employment?*YesNoWill you accept part time employment?*YesNoWill you accept casual employment?*YesNoAre you employed now?*YesNoHow did you learn of this opening? EducationHighest grade completed*89101112131415161718Scholastic honors received:High SchoolName*Location* City State / Province / Region Diploma, Degree or Certificate Received*CollegeNameLocation City State / Province / Region Diploma, Degree or Certificate ReceivedOther EducationNameLocation City State / Province / Region Diploma, Degree or Certificate ReceivedProfessional Licenses and/or CertificationsLicense/Cert. #1TypeOrganization or State IssuedDate Issued MM DD YYYY NumberLicense/Cert. #2TypeOrganization or State IssuedDate MM DD YYYY NumberLicense/Cert. #3TypeOrganization or State IssuedDate MM DD YYYY NumberEmployment Record (List last or present position first.)Present and Former EmployersEmployer 1NameAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Supervisor's Name First Last Phone NumberDate Employed From MM DD YYYY Date Employed To MM DD YYYY Starting SalaryEnding SalaryPosition and DutiesReason for LeavingEmployer 2NameAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Supervisor's Name First Last Phone NumberDate Employed From MM DD YYYY Date Employed To MM DD YYYY Starting SalaryEnding SalaryPosition and DutiesReason for LeavingEmployer 3NameAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Supervisor's Name First Last Phone NumberDate Employed From MM DD YYYY Date Employed To MM DD YYYY Starting SalaryEnding SalaryPosition and DutiesReason for Leaving Employment Record ContinuedPlease explain all periods of unemployment.Have you ever been fired?*YesNoPlease explain.*Have you ever been convicted of or pled "no contest" or "guilty" to a felony, misdemeanor or any other offense other than a minor traffic violation?*Offers of employment are contingent upon criminal background checks and fingerprinting results. A conviction will not necessarily disqualify you from consideration. However, failure to fully disclose will result in immediate denial or termination of employment.YesNoIf so, for what, when, and where?*Are there any felony charges pending against you?*YesNoIf so, for what, when, and where?*Have you ever been or are you currently excluded from any Federal health care program?*The Office of Inspector General (OIG) is authorized to exclude individuals and entities who have engaged in fraud or abuse related to Federal health care programs from participation in Medicare, Medicaid and all other Federal health care programs. YesNoIf so, please state from which program you have been excluded, the date of exclusion, and the reason for the exclusion:*Resume UploadIf you have one, please upload your resume here. (Word document or PDF only, please.)FileReferencesPlease list at least three professional references who are not related to you, and are not a direct supervisor/manager.Professional References*First NameLast NamePhone Number (include area code) Applicant's Additional Comments Applicant Authorization and CertificationI voluntarily authorize Hillsdale Hospital to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies, or corporations supplying such information. I understand any offer of employment will be contingent upon the results of a pre-placement placement medical examination which will include screening for illicit substances, and tobacco. I also acknowledge that if I am in need of any reasonable accommodations during the hiring process or ultimately in order to perform the essential functions of the job for which I am applying, I will notify Hillsdale Hospital as soon as possible. I understand that if I am hired by Hillsdale Hospital, my employment relationship is at-will, meaning that either Hillsdale Hospital or I may terminate the employment relationship at any time, with or without notice and with or without cause. I acknowledge that Hillsdale Hospital may alter my position, job responsibilities, shift and work schedule at its sole discretion. I also understand this provision supersedes any oral or written representations to the contrary, unless I have been provided a written agreement, signed by the President of Hillsdale Hospital that specifically states my employment is not at-will. I certify that the information given by me in this employment application is true, accurate and complete. I understand that if I have given any false information on this application or if I have omitted any material facts, I may be disqualified from employment with Hillsdale Hospital, or, if hired, I may be discharged immediately upon discovery of such misrepresentations or omissions.Name* First Last Date* Date Format: MM slash DD slash YYYY Consent* I agree to the terms of employment. Informed Consent and Release Form for Illicit Controlled Substance ScreeningI understand that, according to Hillsdale Hospital policy which I have read and understand, following a conditional offer of employment, I am required to submit to a pre-placement urinalysis, blood testing, or other screening. I understand that the analysis will be conducted by a qualified testing laboratory. I also understand if I refuse to consent, this will be viewed as my withdrawal from consideration for employment. The purpose of this analysis is to determine the absence or presence of illicitly controlled substances as well as tobacco. I understand a documented chain of specimen custody will be followed to ensure the identity and integrity of my specimen throughout the collection and testing process. If I am offered a position of employment by Hillsdale Hospital, I hereby consent to collection of a specimen of my urine an/or blood for purposes of performing a drug and/or tobacco screening. Furthermore, I hereby release and hold harmless Hillsdale Hospital and its employees and agents from the request to furnish my specimens, the testing of my specimens, and the disclosure of the testing results.Consent* I agree to the above terms and conditions. EmailThis field is for validation purposes and should be left unchanged.
