Bon Secours New York Health System (BSNYHS)

Application for Employment

All new applicants/transfer candidates are required to complete and sign this Employment Application prior to an interview.

Personal Information

* First Name

* Last Name

* Address 1

Address 2

* City

* State

* Postal Code

* Day Phone

* Evening Telephone

* Position Sought

* Date of Application

* Date Availavble for Work

* Social Security No

Reference Source:

* Employee (Name)

* Employment Agency (Name)

* Internet Source

* Relative/Friend (Name)

* College/University

* Others (i.e. job fair, newspaper)

* Type of Employment Desired

* Have you read the job description for which your are applying? If no, please do so before completing the remaining questions on the application.

Yes

No

* Are you able to perform the essential functions of the job for which you are applying with or without a resonable accommodation? If no, please explain.

Yes

No

* Are currently employed by BSNYHS? (if yes, please complete the Internal Transfer Application)

No

Yes

* Are you at least 18 years of age?

Yes

No

* Are you legally eligible for employment in the U.S.? (Proof will be required upon employment)

Yes

No

* Are you available to work overtime and/or weekends if your position requires it?

Yes

No

* Are you available to travel (daily or overnight) if your position requires it?

Yes

No

* Have you been convicted of a crime in the past ten years that has not been annulled, expunged, or sealed by a court? If yes, please describe in full. (Convictions will not necessarily disqualify an application from employment)

Yes

No

* Do you have any criminal charges pending against you? If yes, please explain in full
(Pending charges will not necessarily disqualify an applicant from employment)

Yes

No

EMPLOYMENT HISTORY

COMPLETE THE FOLLOWING INFORMATION. Start with your last/current position held, including military experience & work background. A resume may be attached (only) to describe your duties and scope of responsibility in each job.

* Company

* Employed

* to

* Address

* Telephone

* City

* State

* Zip Code

* Name and Title of Immediate Supervisor

* May we contact?

Yes

No

* Your Title

* Starting base salary

* Final base salary

* Reason for leaving

* Eligible for rehire

Yes

No

Your duties and scope of responsibility

Education

Schools Attended

* High School (Name and Location)

* Did you Graduate?

Yes

No

* Did you Graduate?

Yes

No

* Degree

* Major

* GPA

* Associate Degree (Name and Location)

* Did you Graduate?

Yes

No

* Degree

* Major

* GPA

* Bachelors Degree (Name and Location)

* Did you Graduate?

Yes

No

* Degree

* Major

* GPA

* Masters Degree (Name and Location)

* Did you Graduate?

Yes

No

* Degree

* Major

* GPA

* Doctorate Degree (Name and Location)

* Did you Graduate?

Yes

No

* Degree

* Major

* GPA

* List special accomplishment, publications, awards

Associations

* List professional, trade, business or civic associations and any offices held.

* Organization

* Office Held

* Organization

* Office Held

* Organization

* Office Held

References

Please complete the information below for three business/work references who are not related to you and are not previously listed supervisors. If not applicable, list three school/personal references who are not related to you.
Providing this information means you give BSNYHS permission to contat those individuals listed.

Name

Title

Phone

Years Known

Name

Title

Phone

Years Known

Name

Title

Phone

Years Known

Licenses/Certifications

Professional Organization

License/Certification Number

Expiration Date

PLEASE READ BEFORE SIGNING

If you have any questions regarding the following statements, please ask them of a Human Resources Department Representative before signing this Application. This application is valid for only ninety (90) days. If you have not been employed within ninety (90) days of your application, you must re-apply.

I certify that all of the information given by me on this Application or in supplemental form is true and correct to the best of my knowledge and belief. I further understand that false or misleading statements on this Application or supplemental forms are sufficient cause for my dismissal if I am hired.

I understand that none of BSNYHS's practices or policies are to be construed as imposing any binding obligations on BSNYHS, and that they are subject to change or deletion at any time by BSNYHS in its sole discretion.

I understand that should I be employed with BSNYHS, I will be required, in accordance with the Immigration Reform and Control Act of 1986 (IRCA), to provide on my first day of employment documents providing proof of my identity and employment eligibility status. I acknowledge that this verification is a condition of employment and that failure to comply will void my offer of employment.

I acknowledge that BSNYHS reserves the right to require tests for alcohol or drugs during the course of my employment, consistent with applicable law, including but not limited to the Americans With Disabilities Act. I further authorize any health care professional or testing facility who performs such an examination or who has other information concerning my test results to release such information to BSNYHS. Drug test results with a positive outcome for any illegal substance will result in disciplinary action, up to and including termination of employment.

I acknowledge and certify that I have never been suspended from participation in or subjected to any type of criminal or civil sanction. fine, civil money penalty, debarment or other penalty by any private or public health insurance program, including Medicare, Medicaid. Tricare or any other federal or state health insurance program.

I understand that should I be employed by BSNYHS, my employment is "at will.' At will" means that either party may end the relationship at any time, with or without notice. There is no promise or guarantee of employment or that my employment will continue for any specific period of time.

I understand that any verbal discussions of terms or conditions of employment by BSNYHS representatives are not binding upon BSNYHS unless confirmed in offer letters signed by an authorized BSNYHS executive.

I understand that BSNYHS may contact past employers, educational institutions, various government databases (i.e. HHS/OIG) and references for verification of the information listed in this Application, or provded by me on supplemental documents, and I authorize any such organizations or individuals to provide the requested information.

I hereby acknowledge that I have read and understand each of the above statements.

* Date

* Signature of Applicant

* Indicates Response Required