Application for Employment | Kearny County Hospital

In considering your application for employment, the facility may conduct a detailed and thorough investigation which may include, but is not limited to, a criminal record check. Interviews or inquires of prior employers, co‐workers, acquaintances, relatives or friends.

Name:*

First Last

Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone:*

Email:

Date available to start:*

Desired Salary:

Position(s) you are applying for:*

Advanced Practitioner
CFO
CNA
LPN/RN
Maintenance Tech

If you selected multiple positions, please rank them in the box below in order from your most preferred to least preferred position:

If a current Kearny County Hospital employee referred you to apply, please write their name below:

Are you a citizen of the United States?

Yes
No

If no, are you authorized to work in the U.S.?

Yes
No

Have you ever worked for this company?

Yes
No

If yes, when?

Have you ever been convicted of, or plead guilty to a crime other than misdemeanor traffic violation?

Yes
No

Have you ever been involved in the substantiated abuse or neglect of children or adults under the laws of this or any other state in the United States?

Yes
No

If yes, which state(s), and explain (you are not required to disclose any SEALED or EXPUNGED criminal records):

Have you been sanctioned, cited, reported, or excluded from participation in Medicare, Medicaid, or any other healthcare related law or regulation?

Yes
No

If your answer is "yes" to any of the above, you will not be automatically disqualified from employment consideration, except as required by state or federal law.

Education

High School:

Start Date:

End Date:

Did you graduate?

Yes
No

College:

Degree:

Start Date:

End Date:

Other Education:

Degree:

Start Date:

End Date:

Professional Licenses & Certifications

Type of License/Certification:

License or Registration:

Currently Licensed
Eligible for License
Currently Registered
Eligible for Registration

State:

Date:

License/Certification Number:

Has your License or Certification ever been suspended, revoked or on probation?

Yes
No

If yes, please explain:

Type of License/Certification:

License or Registration:

Currently Licensed
Eligible for License
Currently Registered
Eligible for Registration

State:

Date:

License/Certification Number:

Has your License or Certification ever been suspended, revoked or on probation?

Yes
No

If yes, please explain:

Previous Employment

Company:

Phone:

Supervisor:

Job Title:

Employment Start Date:

Employment End Date:

Beginning Salary/Wage:

Ending Salary/Wage:

Responsibilities:

Reason for Leaving:

May we contact your previous supervisor for a reference?

Yes
No

Company:

Phone:

Supervisor:

Job Title:

Employment Start Date:

Employment End Date:

Beginning Salary/Wage:

Ending Salary/Wage:

Responsibilities:

Reason for Leaving:

May we contact your previous supervisor for a reference?

Yes
No

Company:

Phone:

Supervisor:

Job Title:

Employment Start Date:

Employment End Date:

Beginning Salary/Wage:

Ending Salary/Wage:

Responsibilities:

Reason for Leaving:

May we contact your previous supervisor for a reference?

Yes
No

References

Name:

First Last

Phone:

Relationship:

Company:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name:

First Last

Phone:

Relationship:

Company:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name:

First Last

Phone:

Relationship:

Company:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Language

Please list any language(s) you can speak, read and/or write other than English:

Disclaimer

I hereby affirm the information provided on this (and accompanying resume, if any) is true and complete. I understand that any false or misleading representations or omissions made on the application or during the hiring process may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date. I understand that employment may be conditioned upon successfully passing a medical examination and that I may be required to satisfactorily complete a drug screening as a condition of employment. I hereby authorize persons, schools, my current employer (if applicable) and previous employers and other organizations to provide this facility and its affiliates with any requested information regarding my application or suitability for employment, and I completely release all such persons or entities from any and all liability related to the providing or use of such information. I understand that my employment is at‐will which means that I may terminate the employment relationship at any time and for any reason with or without notice, and that the facility has the same right. I understand that no one has the authority to enter into any agreement contrary to the preceding sentence, except for a written agreement signed by an administrative of this facility and notarized.*

Agree
Do not agree

Submit Resume/CV

Max. file size: 50 MB.

Submit Cover Letter

Max. file size: 50 MB.

How did you hear about career opportunities at Kearny County Hospital?

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