Online Application

January 6, 2009, 8:31 pm

You must understand the terms and conditions in order for this application to submit.

Name:
Last	First	Middle	Social Security No.

Address:
Number/Street	City	State	Zip
Telephone number(s)	E-mail address:

Were you referred to by:
Employee Advertisement School Agency Walk-in Home Page Other


Position Desired:
	Full Time Part Time Temporary Other


Additional Information:
Date of Birth if under 19 yrs.	Date available to start work	What days can you work?	What hours can you work?


Are you a U.S. citizen or legally authorized to work in the U.S?		Do you realized that it may be necessary for you to work weekends, holidays or rotation of shift?
Yes No		Yes No

EDUCATION RECORD: If your employment/education records are under another name, please specify:

	Name of School	Address	Years Completed	Major Course	Diploma/Degree
High School:			1 2 3 4
College:			1 2 3 4
Technical/Trade			1 2 3 4

EMPLOYMENT RECORD - Start with the most recent or current

Have you ever worked for Goodall Hospital or any of its affiliates before? (including, but not limited to, Mt. View Acres, Mayflower Place, Goodall Health Partners, Newton Center, Pavilion, Hillcrest Gardens, June Street Pharmacy, Goodall Express or Prime Care)
No	Yes	If yes, when through


Employer 1:
Name	Mo/Yr	Mo/Yr	Position	Reason for leaving
Street/No.	City	State	Zip Code	Telephone number
Salary	Supervisor	Are you currently employed? Yes No	If yes may we contact your current employer? Yes No

Employer 2:
Name	Mo/Yr	Mo/Yr	Position	Reason for leaving
Street/No.	City	State	Zip Code	Telephone number
Salary	Supervisor	Are you currently employed? Yes No	If yes may we contact your current employer? Yes No

Employer 3:
Name	Mo/Yr	Mo/Yr	Position	Reason for leaving
Street/No.	City	State	Zip Code	Telephone number
Salary	Supervisor	Are you currently employed? Yes No	If yes may we contact your current employer? Yes No


All Applicants: Please place a check mark next to the skills you have
Typing wpm	Switchboard	Word Processing	Transcription
Bookkeeping	Filing	Dictaphone	Medical Terminology

Please list computer skills:


Please list in this section any other skills or special training you may have received that is not listed elsewhere on this application, i.e., cooking, floor refinishing, supervisory skills, maintenance, etc.


Please attach copies of resume, diploma(s), certifcations, training(s), and references:


If Licensing is Required for the Position Applied for, (COMPLETE THIS SECTION)
License Type Profession	License Number	State	Expiration Date

If Certification is Required for the Position Applied for, (COMPLETE THIS SECTION)
Type of Certification	Cert. Number	Association	Expiration Date

If you are not licensed/certified have you applied			Date applied:
Yes No

Terms and Conditions of Employment:

1. Do you know of any reason why, with or without reasonable accommodation, you cannot perform the essential functions of the job for which you are applying? Yes No

2. Do you understand that willfully making false statements on this application may result in discharge, at the sole discretion of Goodall Hospital? Yes No

3. Do you understand that due to the nature of the services we provide, an exceptional record of attendance, promptness, and dependability is required of all hospital employees? Yes No

4. Do you understand that following a job offer, employment is contingent upon the result of a Health Screening examination, satisfactory education, prior employment and reference verifications? Yes No

5. Do you understand that the first 3 months of employment at Goodall Hospital will be considered an introductory period - and that employment may be terminated during this period by either the employee and/or the employer without prejudice and with no eligibility for accrued benefits or service pay? Yes No

6. In answering the following questions, you may omit any information or answer "no record" with regard to any conviction that has been annulled by a court or for which there is a sealed record on file with the Commissioner of Probation. You may omit first convictions for drunkenness, simple assault, speeding, minor traffic violations, affray or disturbance of the peace.

a. Have you ever been convicted of a felony? Yes No

If yes, give dates and details and respond to question C.

b. Have you ever been convicted of a misdemeanor within the last five years? Yes No

If yes, give dates and details and respond to question C.

c. If you answered yes to questions a or b above, have you been convicted of a misdemeanor more than five years ago? Yes No

If yes, give dates and details.

A conviction record will not necessarily be a bar to employment. Factors such as your age when the offense occurred, the recentness of the offense, the seriousness and nature of the violation, the nature of the position applied for, and any rehabilitation undergone may be taken into account.

Do you understand the terms and conditions?Yes No

Please Read This Statement Carefully Before Submitting Your Application

I agree to a Health Screen at H.D. Goodall Hospital and in the event of a work injury, the hospital has my consent for such medical treatment or procedures as its staff and employees may deem necessary in emergency circumstances in the Emergency Unit. In the event I am photographed during the course of my employment, the hospital has my permission to use any and all photos for various public relations purposes.

I acknowledge and agree that just as I am free to terminate my employment with Goodall Hospital at any time at my sole discretion, my employment may also be terminated by the hospital at any time at its sole discretion.

Signature: Though we understand you cannot sign the application on line, a signature will be needed prior to employment.

By submitting this application you hereby authorize Goodall Hospital and its agents to contact and obtain information and records from any of the individuals or employers listed above except for my current employer if I have so indicated.
I also hereby authorize Goodall Hospital and its agents to make reasonable inquiry of and obtain information and records from law enforcement agencies, professional associations, and other entitled in order to make an assessment of my character and fitness for the position for which I am applying. In connection with Goodall Hospital's investigation of my prior work history and character, I hereby waive any and all rights I have against Goodall Hospital and any of their person's and entities it contacts.

The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40, but less than 70 years of age. These applications will be kept on file for one year.

"We are an Equal Opportunity Employer" as outlined in the Federal Civil Rights Act of 1964 and the State of Maine Human Rights Act - 7/1/72 and the Rehabilitation Act of 1973.

In compliance with the Immigration Reform & Control Act. If this application results in employment you will be required to provide proof of identity and authorization to work in the US within 3 days of employment.