APPLICATION FOR EMPLOYMENT
133 PARK STREET APPLICANTS WITH QUESTIONS REGARDING THE APPLICATION PROCESS SHOULD CONTACT THE HUMAN RESOURCE DEPT AT (518) 483-3000 X268.
MALONE, NEW YORK 12953
(518) 483-3000 FAX:(518) 481-2598
www.alicehyde.com
ALICE HYDE MEDICAL CENTER IS AN EQUAL OPPORTUNITY EMPLOYER. STATE AND FEDERAL LAWS PROHIBIT DISCRIMINATION WITH REGARD TO RACE, COLOR, RELIGION, NATIONAL ORIGIN, SEX, AGE, DISABILITIES OR VETERAN STATUS.

Personal Information:
LAST NAME FIRST NAME MI DATE (mm/dd/yyyy)

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STREET ADDRESS CITY STATE ZIP CODE

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EMAIL HOME PHONE (xxx) xxx-xxxx WORK PHONE (xxx) xxx-xxxx
HAVE YOU EVER BEEN CONVICTED OF A CRIME? ARE YOU A U.S. CITIZEN OR LEGALLY AUTHORIZED TO WORK IN THE U.S.? IF YOU ARE UNDER 18, DO YOU HAVE A WORK PERMIT?
YES NO YES NO YES NO
IF YES, PLEASE EXPLAIN: (A PREVIOUS CRIMINAL CONVICTION WILL NOT, UNDER ALL CIRCUMSTANCES, AUTOMATICALLY DISQUALIFY YOU FOR EMPLOYMENT)

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HAVE YOU EVER BEEN EXCLUDED OR SUSPENDED FROM FEDERAL HEALTH CARE PROGRAMS? YES NO (IF YES, GIVE DATE AND EXPLAIN)

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REGISTRATION, LICENSE OR CERTIFICATION NUMBER EXP. DATE
HAS YOUR LICENSE/CERTIFICATION EVER BEEN REVOKED? YES NO (IF YES, GIVE DATE AND EXPLAIN)

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HAVE YOU EVER BEEN EMPLOYED BY AHMC? YES NO (IF YES, SPECIFY DATES AND POSITION HELD)

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ARE YOU RELATED TO ANY PERSON EMPLOYED AT THIS FACILITY? YES NO (IF YES, TO WHOM AND HOW ARE YOU RELATED)

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Positions:
POSITIONS APPLIED FOR AVAILABILITY AVAILABLE TO WORK WEEKENDS HOW DID YOU HEAR ABOUT US?
Position 1:

Position 2:

Position 3:

Position 4: (Type in any position)
 FULL TIME
PART TIME
PER DIEM
SHIFT-WORK		 YES NO NEWSPAPER
FRIEND/FAMILY
TELEVISION
RADIO
INTERNET
JOB FAIR

Education:
CHECK HIGHEST GRADE COMPLETED
GRADE SCHOOL
1 2 3 4 5 6 7 8 		HIGH SCHOOL
9 10 11 12 		G.E.D.
yes no 		COLLEGE OR NURSING SCHOOL
1 2 3 4 		GRADUATE SCHOOL
1 2 3 4
 

HIGH
SCHOOL

NAME OF SCHOOL DEGREE
ADDRESS DID YOU GRADUATE
YES NO
CITY STATE COURSE OF STUDY

COLLEGE
OR
NURSING
SCHOOL

 NAME OF SCHOOL DEGREE
ADDRESS DID YOU GRADUATE
YES NO
CITY STATE COURSE OF STUDY
ADDITIONAL
INFORMATION
OR
TRAINING
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Employment History:
JOB TITLE FROM (mm/yy) TO (mm/yy) IMMEDIATE SUPERVISOR

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COMPANY NAME TELEPHONE NO (INCLUDE AREA CODE)

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ADDRESS

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DUTIES CURRENT SALARY UNDER WHAT NAME?

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REASON FOR LEAVING MAY WE CONTACT THIS EMPLOYER FOR A REFERENCE?

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JOB TITLE FROM (mm/yy) TO (mm/yy) IMMEDIATE SUPERVISOR
COMPANY NAME TELEPHONE NO (INCLUDE AREA CODE)
ADDRESS
DUTIES CURRENT SALARY UNDER WHAT NAME?
REASON FOR LEAVING MAY WE CONTACT THIS EMPLOYER FOR A REFERENCE?
YES NO
JOB TITLE FROM (mm/yy) TO (mm/yy) IMMEDIATE SUPERVISOR
COMPANY NAME TELEPHONE NO (INCLUDE AREA CODE)
ADDRESS
DUTIES CURRENT SALARY UNDER WHAT NAME?
REASON FOR LEAVING MAY WE CONTACT THIS EMPLOYER FOR A REFERENCE?
YES NO
JOB TITLE FROM (mm/yy) TO (mm/yy) IMMEDIATE SUPERVISOR
COMPANY NAME TELEPHONE NO (INCLUDE AREA CODE)
ADDRESS
DUTIES CURRENT SALARY UNDER WHAT NAME?
REASON FOR LEAVING MAY WE CONTACT THIS EMPLOYER FOR A REFERENCE?
YES NO


References: - Please do not use friends or relatives
NAME ADDRESS CITY/STATE/ZIP PHONE OCCUPATION

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IF MORE SPACE IS NEEDED, PLEASE USE THE TEXT BOX AT THE END TO ADD ADDITIONAL INFORMATION

APPLICANT'S AGREEMENT
(PLEASE READ CAREFULLY)
I UNDERSTAND AND AGREE THAT:

All statements that I have made in connection with my application for employment are true, and that I have not withheld any personal information. I understand that any misrepresentation or purposeful omission of facts made in connection with my application for employment or in my interview, are reasons to disqualify me from further consideration and can be grounds for termination if I am hired.
I authorize any person or persons to give Alice Hyde Medical Center representatives any information about me in connection with my application for employment, and release them from any liability for doing so.
I understand that acceptance of a job at Alice Hyde Medical Center may require overtime and weekend work.
I also understand that my application will be valid for 12 months and will not be considered after 12 months has expired.

Please make a selection. CHECK HERE TO INDICATE THAT YOU HAVE READ AND AGREE TO THE ABOVE



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