PCH Employment Application PHYSICIAN'S CHOICE HOSPITAL
ONLINE APPLICATION FOR EMPLOYMENT


We consider applicants for all positions without regard to race, color, religion, creed, national origin, age, disability, sexual orientation, marital status, or any other legally protected status.

INSTRUCTIONS TO APPLICANT
1. You must fully and accurately complete the online Application for Employment. Physician’s Choice Hospital may use the information given in the application to investigate the applicant's previous employment and background.
2. The Application for Employment will be considered inactive after 6 months. If you wish to be considered after that time, you must complete a new Application for Employment.
3.  If you are hired, proof of citizenship or immigration status will be required to verify your lawful right to work in the United States. 
4. Any field marked with a * is a required field and must be completed.
5. In order to submit your online Application for Employement, a valid email address is required. The information that you provide in your online Application for Employment will be emailed to you to retain a a record of your submission.


The following fields are either incomplete or invalid and require your attention.
Please click on each item below to resolve the problePERSONAL INFORMATION

Position(s) for which you are applying for:*
Email Address:*
Title:
 		 First Name:* MI:
 Last Name:*
Address:*
 City:*
 State:*
 Zip:*
Home/Other Phone:*
 Work Phone:
 Cell Phone:
 Best way to contact:
Emergency Contact Name:* 
 Emergency Contact Phone:*

EDUCATION

High School

Name of school: 
 Years completed?
Street:
 Did you graduate?
 Yes  No
City:
 Degree Type:
State:
Zip:
Country:

Associates

Name of school: 
 Years completed?
Street:
 Did you graduate?
 Yes  No
City:
 Degree Type:
State:
Zip:
Country:

Undergraduate

Name of school: 
 Years completed?
Street:
 Did you graduate?
 Yes  No
City:
 Degree Type:
State:
Zip:
Country:

Graduate

Name of school: 
 Years completed?
Street:
 Did you graduate?
 Yes  No
City:
 Degree Type:
State:
Zip:
Country:

Technical

Name of school: 
 Years completed?
Street:
 Did you graduate?
 Yes  No
City:
 Degree Type:
State:
Zip:
Country:

Other

Name of school: 
 Years completed?
Street:
 Did you graduate?
 Yes  No
City:
 Degree Type:
State:
Zip:
Country:

PROFESSIONAL REGISTRATION/LICENSE/CERTIFICATION
License Name:
 State:
 License Number:
 License Expires:
 Current?
 Yes  No 
License Name:
 State:
 License Number:
 License Expires:
 Current?
 Yes  No 
License Name:
 State:
 License Number:
 License Expires:
 Current?
 Yes  No 
License Name:
 State:
 License Number:
 License Expires:
 Current?
 Yes  No 
Have you ever had any professional license or certification suspended, revoked, or put on probation?    
Yes  No     
If yes, please explain:
Is your license or certification currently under investigation?
 Yes  No
If yes, please explain:
Have you ever been denied a license or certification?
 Yes  No
If yes, please explain:

 
WORK HISTORY

Are you currently employed?*
 Yes  No

List all previous employment starting with your most recent position. Account for any time during this period that you were unemployed by stating the nature of your activities. Please indicate if you were employed under a different name.

1. MOST RECENT EMPLOYER

Name of Company:*


Street:*


City/State/Zip:*
 Job Duties and Responsibilities:*
Employer's Phone:*


Job Title:*


Supervisor's Name:*
 Reason For Leaving:*
Employed From:*
 to  		May we contact this employer for a reference?*
Yes   No
Starting Salary:*
 Employment Status:*
Full-Time  Part-Time  PRN 
Ending Salary:*

2.

Name of Company:*


Street:*


City/State/Zip:*
 Job Duties and Responsibilities:*
Employer's Phone:*


Job Title:*


Supervisor's Name:*
 Reason For Leaving:*
Employed From:*
 to  		May we contact this employer for a reference?*
Yes   No
Starting Salary:*
 Employment Status:*
Full-Time  Part-Time  PRN 
Ending Salary:*
 .

3.

Name of Company:*


Street:*


City/State/Zip:*
 Job Duties and Responsibilities:*
Employer's Phone:*


Job Title:*


Supervisor's Name:*
 Reason For Leaving:*
Employed From:*
 to  		May we contact this employer for a reference?*
Yes   No
Starting Salary:*
 Employment Status:*
Full-Time  Part-Time  PRN 
Ending Salary:*
 .

4.

Name of Company:*


Street:*


City/State/Zip:*
 Job Duties and Responsibilities:*
Employer's Phone:*


Job Title:*


Supervisor's Name:*
 Reason For Leaving:*
Employed From:*
 to  		May we contact this employer for a reference?*
Yes   No
Starting Salary:*
 Employment Status:*
Full-Time  Part-Time  PRN 
Ending Salary:*
 .

PROFESSIONAL REFERENCES

Give names and phone numbers of three (3) persons NOT RELATED to you, who are familiar with your work and who you have known at least one (1) year:

Name:
 Phone Number:
 Company:
 Title/Relationship:
Name:
 Phone Number:
 Company:
 Title/Relationship:
Name:
 Phone Number:
 Company:
 Title/Relationship:
Name:
 Phone Number:
 Company:
 Title/Relationship:

ADDITIONAL INFORMATION

How did you find out about this position?*
 If you were referred by a current employee, enter their name:
When will you be available to begin work?*
 Do you have the legal right to work in the United States?
 Yes  No 
Which job status/shift would you accept?*
Full-Time  Part-Time 		 *Are you currently on "layoff" status and subject to recall?
 Yes  No 
*Were you in the U.S. Armed Forces?
 Yes  No 

If yes, which Branch of Service?



Special Training:

 *Have you ever been convicted of a felony?
A yes answer does nto automatically disqualify you".
 Yes  No 


If yes, state nature of conviction & dates.
*Are you now a member of the National Guard or Reserve Unit?
 Yes  No 		 .
Have you ever been excluded or suspended from taking part in any federal or state-funded health care program, including but not limited to Medicare or Medicaid?
 Yes  No 


If yes, explain:
 Are you, or is an employer of yours within the past year, currently under investigation for healthcare fraud, abuse, or misconduct from participation in any Federal or State healthcare program, including Medicare and/or Medicaid?
 Yes  No 


If yes, explain:

Have you ever been discharged by an employer or resigned in lieu of discharge?
 Yes  No 

If yes, explain:

UPLOAD YOUR RESUME
You may upload your resume in either a Word (.doc) or Adobe (.pdf) format. No other file formats will be accepted. To upload your Resume, click on the Browse button and select the file on your computer that you wish to have uploaded when you submit your online application.

AUTHORIZATION AND UNDERSTANDING

Read the following carefully before signing.

I certify all statements made by me on this application are true and complete to the best of my knowledge and without consequential omissions of any kind. I also certify that I have not knowingly withheld any information that would affect this application unfavorably. I understand and agree that any false statement or omissions as discussed above with respect to the information required on this application is grounds for refusal to hire me or for withdrawal of any offer of employment made to me or for the termination of my employment by Physician’s Choice Hospital.

I authorize Physician’s Choice Hospital to investigate all matters covered by this application as well as all statements made by me on this application. I also authorize my previous employers, schools, or other persons named as references or former supervisors to disclose information they may have regarding my suitability for employment and the matters addressed in my application and release them from any liability arising out of their disclosure of information.

I further release Physician’s Choice Hospital and its employees and agents from all liability for damages whatsoever if an employment offer is not tendered to me, or is withdrawn, or if my employment is terminated because of the results of the investigation of this application.

I understand that if I am offered employment with Physician’s Choice Hospital I may terminate my employment at any time with or without cause, and Physician’s Choice Hospital may terminate or modify the relationship at any time with or without cause.

In consideration of my employment, I agree to conform to policies and procedures of Physician’s Choice Hospital.

I understand that if I am offered employment by Physician’s Choice Hospital, the offer is contingent on my passing a background check.

I hereby certify that I am genuinely interested in employment with Physician’s Choice Hospital and acknowledge that I have read and understand the above statements and had the opportunity to ask questions.

My typed name below shall have the same force and effect as my written signature.


Candidate's/Applicant's Signature:
Date:

Please double check your form fields prior to submission. 

Click once on the "Submit Your Application" button to submit your form contents.  The submission process may take a few seconds to process before you are taken to the completed submission page. A copy of your completed application will be emailed to you for your records.

Thank you for your interest!