Employment Application 17 - The Long Island Home

1 South Oaks Hospital Employment Application Title VII of the Civil Rights Act of 1964 400 Sunrise Highway EQUAL OPPORTUNITY EMPLOYER prohibits discrimination based on race, color, Amityville, NY 11701 religion, sex, citizenship, age, handicap, disability, pregnancy and marital status. PLEASE COMPLETE THIS FORM AND FAX IT TO: (631) 264-3801 Position Desired _____ Are You Interested in Full Time On Call/Per Diem Hours Preferred Day Evening Night Part Time Temporary Name _____ First M.

2 Last Address _____ City State Zip Code Social Security Number_____ Phone Number _____ Email_____ How did you find out about us?_____ Were you previously employed by us? Yes If yes, when _____ No Do you have a legal right to work in the Yes No *Proof of lawful Employment eligibility in the United States will be required upon Employment , in accordance with the Immigration Reform and Control Act of 1986.

3 Are you related to anyone in our employ? Yes State name of individual _____ No What is your approximate salary expectation? $_____ RECORD OF Employment (Begin with most recent and include summer jobs) FILL IN ALL SECTIONS Present or Last Employer _____ From _____to _____ Month Year Month Year Address _____Phone Number _____ City State Zip Code Your Position _____ Hours of Work _____ Reason for Leaving _____ Employer _____ From _____ to _____ Month Year Month Year Address _____ Phone Number _____

4 City State Zip Code Your Position _____ Hours of Work_____ Reason for Leaving _____ Employer _____ From_____ to _____ Month Year Month Year Address _____Phone Number _____ City State Zip Code Your Position _____ Hours of Work _____ Reason for Leaving _____ _____ EDUCATION High School Undergraduate College/University Graduate Certificate/ Technical School Name and Location Years Completed 9 10 11 12 1 2 3 4 1 2 3 4 Diploma/Degree Course of Study List any scholastic honors you have received, any specialized training programs, apprenticeships or courses, or any memberships in professional organizations you consider relevant to the position you are seeking.

5 _____ SKILLS/ QUALIFICATIONS (If relevant to the position for which you are applying) Type _____ wpm _____ Familiarity with medical terminology ( ) Other_____(office, word processing, etc.) CPR Certified? ( ) Yes ( ) No Expiration date_____ Issued by _____ NURSES RN LPN Do you possess a current Registration? ( ) Yes ( )No Registration # _____ If no, please complete the following: Have you taken Boards? ( )Yes ( )No Date when scheduled _____ Do you possess current out-of-state registration? ( ) Yes ( ) No If yes: State_____ Registration #_____ Have you applied for Registration: ( ) Yes ( ) No If yes: Date scheduled _____ NURSING ATTENDANTS Are you Certified?

6 ( ) Yes ( ) No Certification # _____ If no, please complete the following: Have you scheduled or taken the examination? Indicate Date _____ MILITARY SERVICE RECORD Were you in the Armed Forces? ( ) Yes ( ) No If yes, what Branch? _____ List job duties, including special training _____ MISCELLANEOUS Have you ever been convicted of a violation of any criminal offense? (Do not include parking violations) ( ) Yes ( ) No If yes, please explain. Conviction of a crime will not necessarily preclude your Employment with the Hospital. _____ _____ Have you ever worked for South Oaks Hospital under a different name?

7 ( ) Yes ( ) No If yes, what name? _____ Is additional information relative to change of name or nickname necessary to check on your references? ( ) Yes ( ) No If yes, please explain _____ CONDITIONS OF Employment I understand that in applying for Employment I must comply with all policies and procedures of South Oaks Hospital and that Employment is contingent upon satisfactory reference verification and passing the pre- Employment physical examination. The facts set forth in my Application are true and complete, to the best of my knowledge.

8 I further understand that any false statements or misrepresentations made by me on this Application or any supplement will be sufficient grounds for dismissal. I hereby authorize you to make any investigation necessary to verify the information provided in this Application and I release the Hospital from any and all liability that might arise from such investigation. Further, I authorize my previous employers to release any and all Employment information concerning me to the Hospital and I release them from any and all liability that might arise from the release of my Employment records.

9 Further, if employed, I understand and agree that my Employment is for no fixed or definite period, and that I may be terminated at any time for any or no reason, subject to applicable law. I understand that this is a tobacco/ smoke free facility. _____ _____ Applicant's Signature Date NOTE: This Application cannot be considered without your signature. _____ (DO NOT WRITE BELOW THIS LINE - HUMAN RESOURCES DEPARTMENT TO COMPLETE) Interviewed by (HR): _____ Date : _____ Dept Interviewer:_____ Remarks: _____ Approved for Hire: Yes ( ) No ( ) _____ _____ _____ F:\USERS\MALLISON\hr forms\NEW HIRE\ Rev: 6/06,11/07,7/08,9/09,2/12, 3/12, 11/17