Columbus Community Hospital

* = Required

Personal Information

First Name*

Middle Name

Last Name*

Other Names (Maiden)

Social Security Number*

Telephone Number*

E-Mail Address

Address*

City*

State *

Zip Code*

Are you legally eligible to work in the United States?*
YesNo

Are you 18 years old or older?*
YesNo

Have you ever worked for Columbus Community Hospital before?*
YesNo

If yes, when?

What department(s)?

Do you have any relatives or friends who work for Columbus Community Hospital?
YesNo

If yes, what are their names?

Who referred you to our hospital?: NewspaperAgencyRelative/FriendWorkforceWebsiteOtherHospital Employee
If Hospital Employee, what is their name?	If Hospital Employee, what is your relationship?

Are you a veteran?
YesNo

If yes, what branch?

When?

Have you ever been convicted of any criminal offense other than a minor traffic violation? If no, type initials here:

If yes, please explain, including offenses for which convicted, dates and location. (Convictions do not automatically bar employment. Nature, date, rehabilitation and relation with job sought will be considered. Non disclosure of a conviction may lead to rescission of the employment offer or termination if employed.).

(Indicate all Schedules and Shifts desired):
SCHEDULE: Full-Time Part-Time Pool/On-Call Temporary	SHIFT: Day Evening Night Weekend Rotating

Exact position you are applying for:

Additional position you are applying for:

Additional position you are applying for:

Rate of pay you expect:
$

Date available to start work:

Current Professional Registration

Type:	Professional License Number:	Expiration Date:	Granted By: (Licensing Board)	State:

Has your license ever been suspended/revoked?
YesNo

If yes, date and reason:

Education Background

High School

Name*

Location (City, State)*

Level Completed
910
1112

Received Diploma
Received GED
None

Date Completed GED/Location

College/University

Name / Location

Location (City, State)

Date Graduated

Level Completed
12
34

Diploma / Degree

Major / Course of Study

Graduate/Professional School

Name / Location

Location (City, State)

Date Graduated

Level Completed
12
34

Diploma / Degree

Major / Course of Study

Employment Record

List your present or most recent employer FIRST. Include military, volunteer, and unpaid work experiences. Account for all time, including periods of unemployment. Resumes may be attached, but we also request that the following information be completed.

Are you employed at the present time?*
YesNo

If yes, may we contact your present employer?
YesNo

Resume Upload

Employer*	Address*	City*
State*	ZIP Code*	Phone*
Job Title*	Rate of Pay*
Employed From*	To*
Primary Duty/Responsibilities*
Reason for Leaving*		Supervisor*

Employer	Address	City
State	ZIP Code	Phone
Job Title	Rate of Pay
Employed From	To
Primary Duty/Responsibilities
Reason for Leaving		Supervisor

Employer	Address	City
State	ZIP Code	Phone
Job Title	Rate of Pay
Employed From	To
Primary Duty/Responsibilities
Reason for Leaving		Supervisor

Employer	Address	City
State	ZIP Code	Phone
Job Title	Rate of Pay
Employed From	To
Primary Duty/Responsibilities
Reason for Leaving		Supervisor

Employer	Address	City
State	ZIP Code	Phone
Job Title	Rate of Pay
Employed From	To
Primary Duty/Responsibilities
Reason for Leaving		Supervisor

Other

Keyboarding Skills?
YesNo

Speed (wpm)

Other Skills? What business machines can you operate? Computer Skills? Software proficiency?

Bilingual?
YesNo

What Language(s)?

List professional, trade, business or civic activities and offices held. You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status:

State any additional information you feel may be helpful to us in considering your application.

PATIENT CARE APPLICANTS - Please check if you have successfully completed any of the following:
ACLS YesNo Exp. Date:	CPR/BLS Cert. YesNo Exp. Date:	PALS YesNo Exp. Date:
NALS YesNo Exp. Date:	Other YesNo Exp. Date:	Other YesNo Exp. Date:

Professional References (Please do not list friends or relatives)

Name*

Phone #*

Address*

Relationship*

Name*

Phone #*

Address*

Relationship*

Name

Phone #

Address

Relationship

PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING THIS APPLICATION FORM.
COLUMBUS COMMUNITY HOSPITAL, INC. (CCH) RESERVES THE RIGHT TO REJECT
ANY APPLICATION WHICH HAS NOT BEEN FULLY COMPLETED.
A NEW APPLICATION WILL BE REQUIRED AFTER 6 MONTHS.

I certify that the information contained in this application is complete and true to the best of my knowledge and that I have not knowingly withheld any facts or information which would affect my employment. I hereby authorize CCH or an agent of CCH to verify the information contained herein and to investigate my employment, education, personal history, criminal history, credit history, and motor vehicle operation history as applicable. In addition, I understand CCH will conduct a check of the Child and Adult Abuse Registry, the Sex Offender Registry and the OIG and GSA Excluded Parties Listings.
I understand that prior to my employment, I must pass a physical assessment, which will include a drug/alcohol screen and an essential functions assessment. I understand that the exam will be provided by CCH. Failure to pass this assessment will be grounds for denial of employment or termination if I am already employed.
I also understand that all offers of employment are contingent upon the successful completion of the above items and that discovery of any falsified, omitted or negative information at any point in time may result in denial of employment or termination if I am already employed.
CCH is tobacco-free. Tobacco use is prohibited on all CCH property.
In accordance with the Drug-Free Workplace Act of 1988, it is the policy of CCH to provide a safe environment for patients, employees and visitors. The illegal manufacture, possession, distribution or use of controlled substances by employees in the workplace is prohibited.
No person shall be denied employment or equal treatment in the administration of salary, benefits, opportunity for advancement or any other terms or conditions of employment because of the person's race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age (40 or older), disability or genetic information.
If employed, I will comply with all rules and regulations for employees of CCH facilities. I understand and agree that neither this form, nor any other written policy or procedure of CCH and its facilities, shall constitute a contract of employment between CCH and myself for either a definite or an indefinite period of time. I further understand that if employed, I may resign at any time and that CCH may terminate or modify the terms and conditions of my employment at any time.
Integrity, Compassion, Accountability, Respect, and Excellence are Values we hold high here at CCH. If employed, I will commit to building an environment that will uphold these high standards.
I understand that any falsification or omission of material and/or information requested may result in denial of employment or termination if I am already employed. Upon my termination, I authorize the release of reference information on my work and will release CCH from any liability whatsoever as a result of any such inquiry and factual disclosers.
I authorize any reference source to provide CCH with any and all information concerning my previous records, any pertinent information they may have, personal or otherwise, and release parties from all liability for any damage that may result from furnishing to CCH.
I understand that CCH operates 24 hours a day, seven days a week, and that weekend work or temporary changes of shift may be required during my employment.
I hereby give consent to any and all prior employers of mine to provide information with regard to my employment with prior employers to Columbus Community Hospital.

I HAVE READ AND AGREE TO THE ABOVE AND HEREBY CERTIFY THAT THE FACTS THAT I HAVE PROVIDED IN MY EMPLOYMENT APPLICATION ARE TRUE AND COMPLETE.
By accepting and submitting this application, I understand and agree to the terms and conditions stated above. I AcceptI Decline