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. 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* MM slash DD slash YYYY Name* First Middle Last Previous Last Names 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 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?* Yes No Are you 18 years of age or older?* Yes No Are you a previous employee of Hillsdale Hospital?* Yes No If so, please indicate approximate dates:* Do you have a visible tattoo?* Yes No Is it visible under standard work attire?* Yes No Employment InformationPosition(s) You're Applying For*LPN | Full Time (Nights) | Emergency DepartmentCook / Food Service | Full Time (Days) | DietaryRegistered Nurse / RN | Full Time (Nights) | Med SurgNursing Assistant | Part Time (Evenings) | SNFSurgical Technologist | Full Time (Days) | SurgeryRegistered Nurse / RN | Full Time (Mid Shift) | Emergency DepartmentMaintenance & Floor Care | Casual / as needed | MaintenanceMedical Assistant | Full Time (Days) | Hillsdale Health and Wellness ClinicDietary Aide / Food Service | Full Time | Hospital Kitchen, Patient Rooms and CafeteriaMedical Office Receptionist | Full Time (Days) | Hillsdale Health & Wellness ClinicPsychiatric Technician | Casual | Behavioral HealthLPN or RN | Full Time (Nights) | Skilled NursingRegistered Nurse / RN | Full Time (Nights) ER / EDNurse Supervisor | Full Time | Med SurgPsychiatric Technician | Full Time (Days) | Behavioral HealthLaundry Worker | Full Time (Days) | HousekeepingHousekeeper / Custodian / Janitor | Full Time | HospitalMedical Assistant | Casual (as needed) (Days) | Outpatient ClinicsDietary Aide / Food Services | Casual / Per Diem | Nutrition ServicesRegistered Nurse / RN | Full Time (Days) | ER / EDNursing Assistant | Full Time (Nights) | Med / SurgMedical Office Receptionist | Per Diem / Casual (Day Shift) | Offsite Hospital ClinicsRegistered Respiratory Therapist ( RRT) | Casual | CardiopulmonaryMedical Technologist OR Medical Laboratory Technician | Full Time | 2nd shift | LabNuclear Medicine Technologist | Casual | Medical ImagingRegistered Nurse Case Manager | Part Time (Days) | Home CareAdmitting Representative | Casual | AdmittingUltrasound Technologist | Casual | Medical ImagingCertified Midwife | Full-Time (Days) | OB/GYNPhysician or Advanced Practice Provider | Full-Time, Part-Time, CasualGeneral ApplicationWage Expectations* Will you accept another position?* Yes No If so, what? Are you available to work weekends?* Yes No Are you available to work holidays?* Yes No Are you available to work rotating shifts?* Yes No Are there any days or hours you cannot work? Will you accept full time employment?* Yes No Will you accept part time employment?* Yes No Will you accept casual employment?* Yes No Are you employed now?* Yes No How did you learn of this opening? EducationHighest grade completed* 8 9 10 11 12 13 14 15 16 17 18 Scholastic honors received: High SchoolName* Location* City State / Province / Region Diploma, Degree or Certificate Received* CollegeName Location City State / Province / Region Diploma, Degree or Certificate Received Other EducationName Location City State / Province / Region Diploma, Degree or Certificate Received Professional Licenses and/or CertificationsLicense/Cert. #1Type Organization or State Issued Date Issued Month Day Year Number License/Cert. #2Type Organization or State Issued Date Month Day Year Number License/Cert. #3Type Organization or State Issued Date Month Day Year Number Employment Record (List last or present position first.)Present and Former EmployersEmployer 1Name 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 Supervisor's Name First Last Phone NumberDate Employed From Month Day Year Date Employed To Month Day Year Starting Salary Ending Salary Position and DutiesReason for Leaving Employer 2Name 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 Supervisor's Name First Last Phone NumberDate Employed From Month Day Year Date Employed To Month Day Year Starting Salary Ending Salary Position and DutiesReason for Leaving Employer 3Name 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 Supervisor's Name First Last Phone NumberDate Employed From Month Day Year Date Employed To Month Day Year Starting Salary Ending Salary Position and DutiesReason for Leaving Employment Record ContinuedPlease explain all periods of unemployment.Have you ever been fired?* Yes No Please 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. Yes No If so, for what, when, and where?*Are there any felony charges pending against you?* Yes No If 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. Yes No If 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.)FileMax. file size: 200 MB.ReferencesPlease 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. 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* 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. 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 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. CommentsThis field is for validation purposes and should be left unchanged.
