Employment Application
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. All qualified applicants will receive equal consideration (as required by applicable federal and state law) without regard to race, age, creed, religion, gender, national origin, ancestry, disability, veteran status, marital status or sexual orientation.


Personal Information

Providing information regarding your age, race, gender or other protected status is voluntary and this information will be held in strictest confidence. It in no way affects the decision regarding your employment opportunity. This information will not be used in a manner inconsistent with Equal Opportunity principles.

* Indicates Mandatory Fields
First Name: *
Middle Initial:
Last Name:*
Address 1:*
Address 2:
City:*
State:*
Zip:*
Home Phone: (xxx-xxx-xxxx)
* Please provide at least one phone number
Cell Phone: (xxx-xxx-xxxx)
E-mail:
Primary position:*
Secondary position:
Recruiting Source:
If Other:
If referred by an Employee, please provide Employee name:
Have you filed an application with St. Camillus before?
If yes, when?
Have you ever been employed at St. Camillus before?*
      If yes, specify where:
      If yes, specify when:
      If yes, specify the reason you left:
Date available to start:* (MM/DD/YYYY)"
Available to work:
Full-Time  Part-Time  Shifts  Weekends  Holidays  As Needed (PRN)  
Please specify any days or hours not available to work
Have you ever been convicted of a crime (except traffic tickets) including misdemeanors or felonies?
      If yes, please explain:
A criminal record does not constitute an automatic bar from employment.


Employment History: If ANY part of any of the Employment History sections is filled in, then ALL mandatory parts of THAT section must be filled in. Also check that To date is not earlier than From date.

Please list your 2 most recent employers.

1.
Employer's Full Name:*
Address:*
City:*
State (U.S. only):*
Country:*
Zip:*
From Date:* (MM/YYYY)
To Date:* (MM/YYYY)
Supervisor Name:*
Phone:* (xxx-xxx-xxxx)
Salary per
Hours per Week:
Job title:*
<
Type of work and Duties:*
(Limited to 1000 characters)
Reason for Leaving:*
2.
Employer's Full Name:*
Address:*
City:*
State (U.S. only):*
Country:*
Zip:*
From Date:* (MM/YYYY)
To Date:* (MM/YYYY)
Supervisor Name:*
Phone:* (xxx-xxx-xxxx)
Salary per
Hours per Week:
Job title:*
Type of work and Duties:*
(Limited to 1000 characters)
Reason for Leaving:*

Education and Training


1.

Institution Name

Years

Major

Diploma Type

Graduate

 
Comments:

Licenses/Certifications Held

Please list your current license/certificate that is applicable to the position for which you are applying. If you have additional licenses/certifications, please list them in the General comments section below.

1.

Type

Number

State (U.S. Only)

Country

Expiration Date
(MM/DD/YYYY)

 
Comments:
General comments (200 characters)



Applicant Statement


Please read the following information carefully. By checking the "I accept this statement" box below, you are agreeing to the following:

1. I understand that receipt of this application does not imply I will be employed nor does it indicate there are positions available.
2. I understand that unless acted upon, this application will become inactive after 90 days. After that time, I will have to reapply to receive further consideration.
3. I understand that any future offer of employment is contingent upon my passing the prescribed physical examination, TB skin test or chest x-ray, and drug screen. I authorize the Clinic to release and communicate to St. Camillus (Employer), its medical review officer (MRO), its human resources representative and /or designee (s), all results and analyses of all tests performed on me by the Clinic at the request of the Employer for the purpose of the Employer evaluating me for hiring and for the purpose of Employer’s use in any other employment–related situation, as the employer deems appropriate. I understand that the information released by the Clinic to the Employer and/or the MRO will become a permanent part of my application and/or medical record, to be used in the same manner as the rest of my application and /or medical record. I understand that I have a right to inspect and receive a copy of the information to be released to the Employer and the MRO. I understand I have the right to refuse a drug screen and I understand that St. Camillus will consider this cause for rejection of this application. Once my test results are provided to Employer, I understand it is too late to withdraw my consent for the Clinic to share the information with the Employer.
4. I hereby grant permission to investigate any of the information included in this application, agree to cooperate in such investigation and release from all liability or responsibility all persons, organizations, companies and corporations collecting and supplying such information together with any other information they may have regarding me whether or not it is in their records.
5. In making this application for employment, I understand that an investigation may be made whereby information is obtained through interviews with my references, including but not limited to, former co-workers, supervisors, business associates, etc. or others with whom I am acquainted. This inquiry includes information as to my criminal record, reputation, professional credentials, and work ethics. I understand that I have the right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of this investigation.
6. I understand that if I am hired, my employment will be at-will and may be terminated with or without cause and with or without notice at any time. I also understand that no employee of St. Camillus other than the Chief Executive Officer has authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing.
7. I certify the information included in this application is correct and understand that misrepresentation is just cause for rejection of this application or dismissal from employment.
I have read, I understand, and I accept the above statement (please check box to initial)


Attach Resume If Desired, PDF preferred. If Submit results in errors / incomplete fields, it will NOT be necessary to re-attach the Resume before clicking Submit again.

Please Click Submit ONE Time--Response may take a minute or more. Clicking multiple times may result in your application NOT being processed.