APPLICATION FOR EMPLOYMENT

PLEASE COMPLETE APPLICATION IN FULL

Name Last First Middle Current Address Street City State Zip Code Social Sec. Number - - Phone Home: - - Phone Work: - - Can you provide proof, if hired, that you are eligible to work in the United States? Yes No Have you ever pled guilty of a crime or been convicted of a crime, other than a minor traffic violation? Yes No If yes, please explain (Convictions are not an absolute bar to employment but will be considered in relationship to the job requirements.) How did you learn about this opening? Position/s Desired -Choose- Dietary Aide Licensed Practical Nurse Medical Records Clerk Registered Nurse -Choose- Dietary Aide Licensed Practical Nurse Medical Records Clerk Registered Nurse MARK ALL THAT APPLY Type of Employment Full-Time Part-Time Flex-Time Work Schedule/Shift Days Evenings Nights Hours Available Weekends Yes No Rotating Weekends Yes No Current Salary     Minimum Salary Requirement     Date Available to Work (mm/dd/yyyy) Check all that you have experience with: PC LAN Windows Medical Terminology List specific software programs you have used: Typing Speed: WPM Have you graduated from High School or completed the GED equivalent? Yes No List all degrees that you have received. List your HIGHEST DEGREE FIRST. DO NOT list degrees that you are currently working toward. Major Degree School Graduation Date Are you currently enrolled? Yes No     Last Year Attended     Major Check last level of school completed: Undergraduate: Freshman Sophomore Junior Senior Years Completed: 1st Year 2nd Year 3rd Year 4th Year List all professional licenses, registrations, and certifications License Type State Number Expiration Date Do you have any pending restrictions and/or suspensions on your current professional license/registration that would restrain you from performing in this position: Yes No Have you ever been refused professional licensure, or had a license/registration suspended or revoked? Yes No If Yes, please explain: List any trade or professional organizations of which you are a member, include offices held: List any special skills: Start with your most recent employment, give a complete record of employment for the PAST TEN YEARS and reasons for periods of unemployment. NOTE: If additional space is needed for your employment record, please attach a separate sheet. How many years of experience do you have related to this position? MAY WE CONTACT YOUR CURRENT EMPLOYER? Yes No NOTE: If your current or most recent employer is not contacted before an offer of employment is made, then any offer of employment that is made will be subject to the Richard P. Stadter Psychiatric Center or Center for Psychiatric Care subsequently contacting such employer, and may be withdrawn based on the information received from such employer. If no, why? Company Name Your Title Final Salary Type of Business Address  Street: City State Zip Code Duties Date Began Reason for Leaving Supervisor Name & Title:  Supervisor Phone No:    - - Date Left Company Name Your Title Final Salary Type of Business Address  Street: City State Zip Code Duties Date Began Reason for Leaving Supervisor Name & Title:  Supervisor Phone No:    - - Date Left Company Name Your Title Final Salary Type of Business Address  Street: City State Zip Code Duties Date Began Reason for Leaving Supervisor Name & Title:  Supervisor Phone No:    - - Date Left IF YOUR EMPLOYMENT RECORDS EXIST UNDER ANOTHER NAME, PLEASE SPECIFY. If you have a resume to attach, do so here: (.doc, .rtf, .pdf or .txt files only) GIVE THREE ADDITIONAL WORK-RELATED REFERENCES Name Occupation Address Phone Years Known Name Occupation Address Phone Years Known Name Occupation Address Phone Years Known Name Occupation Address Phone Years Known CERTIFICATION AND AGREEMENT I certify that the information I provided in this application is complete and accurate to the best of my knowledge. I understand that any misrepresentation or omission of facts in this application disqualifies me from further consideration, or, if I am employed, is sufficient cause for dismissal. I authorize investigation of all statements contained in this application and understand that I may be required to provide verification (diploma, license, transcripts, etc.) of information contained in this application. I authorize any and all persons, companies or agencies to release to Center for Psychiatric Care (CPC) and/or the Richard P. Stadter Psychiatric Center any and all information they may have which is relevant to the application process. I also release all such parties from any liability that may result from furnishing information to CPC and/or the Richard P. Stadter Psychiatric Center. I understand that to be considered as a formal applicant, the position for which I am applying must be specifically identified as open, and recruitment for the position going on at the time this application is received by the Human Resources Department. I understand that if I am employed, my employment will be at-will. As such, it can be terminated by either party with or without any notice, at any time, and for any reason not prohibited by law. I agree that if I am employed by CPC or the Richard P. Stadter Psychiatric Center, I will review the information contained in CPC or the Richard P. Stadter Psychiatric Center's Employee Handbook. I understand that any employment offer is contingent upon the following: (1) producing documents establishing my eligibility to work in the United States; (2) criminal background and reference checks; and (3) complying with CPC or the Richard P. Stadter Psychiatric Center's pre-employment application procedures. By writing or signing my name and submitting this application to CPC or the Richard P. Stadter Psychiatric Center, I acknowledge that I have read the certification and agreement and agree to abide by its terms. I agree to the terms and conditions listed above. Name:    Date: 07/25/2008    Center for Psychiatric Care and the Richard P. Stadter Psychiatric Center give all applicants for employment equal consideration regardless of race, color, gender, religion, national origin, age, sexual orientation, marital status, or disability. The decision to hire an applicant is based solely on individual qualifications that meet the job requirements.