St Lucie Medical Center Employment Application

Applicant name (Please give complete name)

Phone #

Are you at least 18 years old?
Yes No

Email Address

Present Address

City

State

Zip

Previous Address (if at present address less than 7 years)

City

State

Zip

Current open position(s) for which you are applying
1)
2)
3)

Type of Position (check at least one)

Per Diem	Pool
Full Time	PRN
Part Time	Temporary

Shift (check at least one)

Weekend	Day
Night	Evening
Rotation

Salary Requirement	Are you willing to travel? Yes No	Are you willing to relocate? Yes No	Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours? Yes No
If overtime work is required periodically does this pose a problem for you? Yes No		Date Available for Work	Are you currently employed? Yes No
Are you legally authorized to work in the U.S.? Yes No			Are you related to any other facility employee? Yes No	If Yes, Employee's Name
Have you ever worked in a facility associated with St. Lucie Medical Center/HCA? Yes No			If yes, what facility?	Dates of Service:
			Department:	Title

How did you learn about this position?

State Commission

Agency

Ad

Job Fair

School

Internet

Job Line

Current Employee

Other:
If you checked Current Employee or Other, please indicate in the space above
Also use the other box if a school or agency referred you.

Have you ever been convicted of a felony?
Yes No
If yes, list date, offense and disposition of the conviction. (Convictions are not an automatic disqualification from employment)

Are you presently charged with any violation of the law? Yes No
If yes, please explain:

Are you currently excluded, suspended, debarred or otherwise ineligible to participate in the federal healthcare programs or have you been convicted of a criminal offense related to the provision of healthcare items or services but have not yet been excluded, debarred, or otherwise declared ineligible.
Yes No

Educational History

Type of School	Name of School	Check Last Year Attended in School	Degree or Certificate If contacted to interview, must be able to present valid certificates
	City, State
High School/ GED		9 10 11 12 Graduated/GED? Yes No

College		1 2 3 4 Graduated? Yes No

College		1 2 3 4 Graduated? Yes No

Graduate School		1 2 3 4 Graduated? Yes No

Other		From (Year) To (Year)

List any professional licenses, registration or certifications you possess

Type	State Issued	Exp Date (mm/yyyy)	License Number
1)
2)
3)
4)

Clerical or other skills applicable to
the position for which you are applying.

Typing ( wpm) PBX
Proficient in Software: (list all)

Business machines and/or equipment you can operate:
Other:

Employment History

Please provide a minimum of the most recent 10 years employment history including any period of unemployment. Attach additional pages if needed.

Current or Most Recent

From

Company

Address

Phone Number

Immediate Supervisor

Salary

May we contact them?
Yes No

Name While Employed, if different than the name on application

Job Title

Other reference with this employer

Reason for Leaving

Nature of Duties

First Previous

From

Company

Address

Phone Number

Immediate Supervisor

Salary

May we contact them?
Yes No

Name While Employed, if different than the name on application

Job Title

Other reference with this employer

Reason for Leaving

Nature of Duties

Second Previous

From

Company
Address

Phone Number

Immediate Supervisor

Salary

May we contact them?
Yes No

Name While Employed, if different than the name on application

Job Title

Other reference with this employer

Reason for Leaving

Nature of Duties

Third Previous

From

Company

Address

Phone Number

Immediate Supervisor

Salary

May we contact them?
Yes No

Name While Employed, if different than the name on application

Job Title

Other reference with this employer

Reason for Leaving

Nature of Duties

Professional References (Other than Relatives)
Give two references who have good knowledge of your work.

Name

Position

Address (Include City/State)

Phone Work/Home

Number of years Known

Please Review and Sign Where Indicated

In making application for employment:
I certified that the information in this application is true and complete for all practical purposes. It may be verified by the facility or any affiliate. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the facility or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.

I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable. If such an investigative report is made, I understand that I will receive notice that such report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.

I understand and agree that any employee handbook which I may receive will not constitute an employment contract, but will be merely a gratuitous statement of facility policies.

I understand that the facility reserves the right to require its employees to submit to blood tests or urinalyses for alcohol or drug screens, or to allow inspection of bags (including purses or briefcases) or parcels brought in or taken out of the facility. I understand that refusal to submit to a urinalysis, blood test or search, when requested to do so, may result in termination of my employment.

Compliance with this facility's Substance Abuse Policy is a condition of employment. This hospital requires that every newly hired employee be free of alcohol or drug abuse. Each offer of employment is contingent upon successfully completing a urinalysis test/screen for alcohol and drugs in accordance with hospital policy. Continued employment is also contingent upon compliance with the hospital's Alcohol and Drug Abuse Policy.

I agree to immediately disclose to the Company any debarment, suspension, exclusion or other event that makes me ineligible to participate in any federal health care program, or receive a government contract.

I understand and agree that if I am offered employment by the facility, my employment will be for no definite term and that the facility may terminate the employment relationship for cause. Cause is defined as a reason for disciplinary action that is not arbitrary, capricious, or illegal, that is based on facts that the employer reasonably believes to be true. Some examples of cause include, but are not limited to, (1) dissatisfaction with an employee for such reasons as lack of capacity or diligence, failure to conform to usual standards of conduct, or other culpable or inappropriate behavior, or (2) economic needs subject to the reasonable judgment of the employer.

Release:
I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my licensure status and my licensure history.

I have read and understand
these conditions of employment.
Yes

Please enter your initials in the box to the left.
By clicking on "send," I hear by attach my signature to this employment application as evidence that I have agreed to the above.