NIAGARA FALLS MEMORIAL MEDICAL CENTER / SCHOELLKOPF HEALTH CENTER

621 Tenth Street, Niagara Falls, NY 14302

APPLICATION FOR EMPLOYMENT

(Please Print or Type)

Name: Last / First / MI / Social Security Number
Address: No. / Street / City / State Zip
Position Desired: / Telephone Number
How were you referred to us: / Employee / Ad / Community or other Agency / Other:______
Full Time / Part Time / Temporary / Summer / Per Diem
Circle days you can work: S M T W T F S / Shifts: Day Evening Night
Date Available to Begin: / Are you Legally qualified to be Employed in the USA?
Yes No
Proof of Citizenship or immigration status will be required upon employment
Have you ever been offered a position OR employed at Niagara Falls Memorial Medical Center / Schoellkopf Health Center?
Yes No
If yes Dates: / Positions Offered / Held (list all)
Are you related to anyone employed here Yes No
If yes: (name) / Relationship:
The New York State Human Rights Law prohibits discrimination in employment because of age.
Are you over 18 years of age? Yes No
EDUCATION
Name & Location of all High Schools, Vocational Schools, Business Schools, Colleges, and Related Military Courses attended. / Course of Study / Diploma/Degree received or Reason for leaving. (if not graduated, credit hours completed)
School
Address
School
Address
School
Address
To enable a check of your school and work records, have you attended school or worked under any other name(s)?
Yes NO (list if yes)
Professional License or Registration
If you have a Professional or Technical License, Registration, Certification, or Permit complete the following:
Type: / Number: / Issued by:
State: / Date: (from) / Date: (to)
Provide the past 10 years of employment as completely as possible. Starting with your present or most recent employer, including summer employment. If space is insufficient; list on an additional page or attach resume. For any unemployed or self-employed periods, show dates and locations. All data must be completely filled in. DO NOT write “see resume”.
Name and Address of Company / Dates / Nature of Experience/Job Title/Supervisor / Pay Rate / Reason For Leaving
1. / From
To
2. / From
To
3. / From
To
4. / From
To
May we contact your present employer? Yes No if NO please explain:
Please list below at least two Professional/Employment Supervisory References:
NAME ADDRESS/PHONE NUMBER TITLE/OCCUPATION
1.
______
2.
______
3.
______

Release: I hereby declare that all the above statements are true and correct to the best of my knowledge, and authorize Niagara Falls Memorial Medical Center and /or Schoellkopf Health Center to inquire into all matters contained in this application including my educational and work records, with the understanding that any misrepresentation or omissions made herein will be just and due cause for my discharge from employment. I understand that I may be rejected for employment and may be discharged for falsifying or misrepresenting any information contained in this employment application, pre-employment physical or during the interview process. I may be terminated regardless of when the falsification or misrepresentation is discovered. I release all organizations, schools, or persons providing information relevant to my employment qualifications from all liability for any ensuing damages. I understand that nothing contained in this application or in the granting of an interview is intended to create an employment contract of any kind. I also certify that I understand that if hired, my employment is at will and can be terminated by Niagara Falls Memorial Medical Center and/or Schoellkopf Health Center, or me at any time for any reason.

As part of Niagara Falls Memorial Medical Center/Schoellkopf Health Center’s effort to provide a safe and healthy work environment free from alcohol and drug abuse, all applicants who are being considered for employment will be required to undergo a drug screening before an employment decision is made. A positive test result will make an applicant ineligible for employment. I understand that ineligibility for employment is neither defined nor time limited.

I agree to submit to a Post Job Offer Physical and I also realize that as an applicant I may be asked to provide a sample of my hair, urine and/or blood and consent to such testing for drugs and alcohol. Satisfactory completion of the Post Job Offer Physical and any other Physical Examination (i.e. drug and alcohol tests) is required for employment.

Signature: Date:

Federal and State Laws prohibit discrimination in employment because of age, color, creed, handicap, marital status, national origin, race, sex, religion, disability or veteran status.

Niagara Falls Memorial Medical Center / Schoellkopf Health Center is an Equal Opportunity Employer