Last Name:

First Name:

Middle Initial:

Present Address:

City:

State: Zip:

Home Phone :

Work Phone :

Cell Phone :

Email Address :

Date of Application:

If hired, can you provide written evidence that you are authorized to work in the United States? YES NO

Are you 16 years of age or older? YES NO

Have you ever been employed at St. Anthony? If yes, please list position/dates: YES NO 250 characters remaining

Do you have a record of founded child or dependent adult abuse in this state or any other state? If yes, please give dates and explain: YES NO
250 characters remaining

Have you ever been convicted of a crime or pled guilty to a crime or violation other than a minor traffic offense? A conviction record will not necessarily automatically disqualify you for employment. The circumstances of the conviction will be considered in relation to the nature and duties of the job for which you apply. YES NO

If yes, please give dates and explain:
250 characters remaining

Are there any other names under which your employment or educational records, references, and other information may be verified? YES NO

If so, please list:
250 characters remaining

Positions Applying For:

Position Title 1:Position Title 2:Position Title 3:

Status you are interested in: Full Time Part Time Relief/PRN Weekend Pkg

Are you willing to work (check all that apply): Days? Evening? Nights? Weekends

Specify the hours per week you are interested in: Minimum: Maximum:

Are you employed now: YES NO Available Start Date

**Please understand that you are applying with a health care organization and that you may be required to work any day, Monday through Sunday, any shift and number of hours to meet the needs of our patients and residents.

Please give a COMPLETE record of all employment and military service and START with present or most recent employer. DO NOT use “Refer to Resume.”

May we contact your present employer for references? Yes No Not at this time.
If “No” or “Not at this time” please explain:
250 characters remaining

Name of Employer :

Dates Employed : From :(MM/DD/YYYY) To :(MM/DD/YYYY or Present)

Address:

City:

State: Zip:

Name of Supervisor : Phone # :

Position Held :

Approx. Hrs. Per week: Last rate of pay :

Reason for leaving : 250 characters remaining

Name of Employer :

Dates Employed : From :(MM/DD/YYYY) To :(MM/DD/YYYY or Present)

Address:

City:

State: Zip:

Name of Supervisor : Phone # :

Position Held :

Approx. Hrs. Per week: Last rate of pay :

Reason for leaving : 250 characters remaining

Name of Employer :

Dates Employed : From :(MM/DD/YYYY) To :(MM/DD/YYYY or Present)

Address:

City:

State: Zip:

Name of Supervisor : Phone # :

Position Held :

Approx. Hrs. Per week: Last rate of pay :

Reason for leaving : 250 characters remaining

Name of Employer :

Dates Employed : From :(MM/DD/YYYY) To :(MM/DD/YYYY or Present)

Address:

City:

State: Zip:

Name of Supervisor : Phone # :

Position Held :

Approx. Hrs. Per week: Last rate of pay :

Reason for leaving : 250 characters remaining

High School
Name:

Address:

City: State:

Did you graduate:

College
Name:

Address:

City: State:

Did you graduate:

Dates Attended From: (MM/DD/YYYY) To: (MM/DD/YYYY)

Degrees & Major: GPA:

Other
Name:

Address:

City: State:

Did you graduate

Dates Attended From: (MM/DD/YYYY) To: (MM/DD/YYYY)

Degrees & Major: GPA:

Professional Licenses and/or Certifications (IF APPLICABLE)

Type

License/Certification Number State Issued :

Expiration Date: (MM/DD/YYYY) Verification (HR Use Only) :

Other Skills (e.g. typing, WPM, Medical Terminology, Transcription, etc.): 250 characters remaining

Name :

Organization :

Title :

Relationship to Applicant :

Home/Cell Phone : Work Phone :

Name :

Organization :

Title :

Relationship to Applicant :

Home/Cell Phone : Work Phone :

Name :

Organization :

Title :

Relationship to Applicant :

Home/Cell Phone : Work Phone :

How did you learn of this job opening? (Answering this question is voluntary and will not affect employment eligibility):

St. Anthony web site – www.stanthonyhospital.org

St. Anthony employee – please name :

Newspaper ad – please name paper :

Other – please explain : 250 characters remaining

Reference Authorization:
Having made an application for employment with St. Anthony Regional Hospital & Nursing Home (SARH&NH), I hereby authorize them to investigate my past and ascertain any and all information which may concern my character, work record, and educational history. By pressing the submit button below, I hereby release from liability or responsibility all persons, companies or corporations supplying this information.

Applicant Certification: I certify that the information provided in this application is true and accurate and I understand and agree that the falsification, misrepresentation or omission of any information in this application are grounds for withdrawal of a job offer or if I have been hired, grounds for termination. I authorize release of employment, salary, education, and other related records to SARH&NH for the purpose of checking my references and verifying my employment and educational history. I understand and agree that if, in the judgment of SARH&NH, the results of the investigation are not satisfactory, any offer of employment made by SARH&NH may be withdrawn or my employment with SARH&NH may be terminated. I release all parties from liability for any damages which may result from the release of any information as a part of the employment verification process. I understand SARH&NH will obtain a criminal, child and dependent adult abuse record check on applicants before employment. I acknowledge that I understand SARH&NH has a policy of employment at will and if I am hired, my employment can be terminated with or without cause and with or without notice at any time at the option of either SARH&NH or myself. I understand that all successful applicants must pass a physical examination prior to beginning employment at SARH&NH and an offer of employment is contingent upon my passing the medical examination before starting work. The examination may include a demonstration of my ability to perform the essential functions of the job. If the examination discloses conditions that prevent me from safely and successfully performing the essential functions of the job, SARH&NH will attempt to make accommodations that will enable me to work. If no reasonable accommodations can be found, or if such accommodations impose undue hardship on SARH&NH, the offer of employment will be withdrawn. I also understand that, upon receiving a conditional offer of employment, it will be contingent upon successfully passing a postoffer drug test. I understand that employment is contingent upon successful completion of a job-required licensure, certification, or registration exam, if applicable and not already completed. In consideration of employment, I understand that emergency conditions may require me to temporarily work shifts other than the one for which I am applying and agree to such scheduling changes as directed by my department manager or administrator. If hired, I further agree to conform to all policies, rules and regulations of SARH&NH and understand that the terms, conditions, compensation, benefits, hours, schedule and duration of my employment (whether set forth in the employment handbook or not), may be determined, changed or modified from time to time at the will of SARH&NH without limitation or agreement. I acknowledge that I have been advised that this application will remain active for one year from this date.

Hospital Survey:
Thank you for completing the St. Anthony Regional Hospital Application for Employment. Please click here to complete the St. Anthony Regional Hospital Survey. The Survey is an important part of our application process; therefore Applications for Employment without a completed Survey will not be accepted.

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