Granville Health System Application for Employment
 When complete, click on the "Submit" button (once) located at the bottom of the page.

We offer equal opportunity to all, based upon individual merit, and do not discriminate on the basis of race, color, religion, national origin, sex, disability, age or any other basis protected by the state law, unless required to do so by law or bona fide occupational qualifications.  The questions on this application form are intended to be nondiscriminatory in nature and applicants are not required to submit any information which could be used for discriminatory purposes.

Personal Information

Name:           Date:   
First                                      Last                                  Middle                                           
Please indicate any other name or names you may have had which we would be required to check your record: 

Address:
                          Number                            Street                                         City                                 State                   Zip           

Home Telephone Number:     Other Telephone Number: 
                                                    (please include Area Code)                                                             (please include Area Code)

Social Security Number:     Are you over 18?    Are you a US Citizen?  
If you are not a citizen, have you the legal right to remain permanently in the US? 

Have you ever been convicted of a crime, either a felony or a misdemeanor?    (prior conviction does not automatically bar employment) If yes, please list the date and place of the offense, law, charge law and disposition. 
Include any conviction as a result of Military Court Martial.  

Employment Information
Position Applied for:  1.  Status Desired:     Date Available for work: 
Position Applied for:  2.  Status Desired: 
Days available for full or part-time work:  Whenever Required Sun Mon Tue Wed Thur Fri Sat 
Shift(s) available:  First (days)  Second (afternoons)  Third (nights)  Any  Regular office hours 
Preferred shift: 
Have you ever been employed by this organization?    If yes, when? 
Friends or relatives employed by this organization: 

Is there anything which could interfere with your ability to perform the duties of the above positions? 
If yes, explain.

Education and Training
 

Name

City / State

Dates Attended
From       To   

Type of diploma
or degree

Year
Graduated
High school  

Diploma
GED

  
College
College
Grad. School
Other
Degrees

List training programs, extracurricular activities, or other educational experiences relevant to position(s) applied for:

Experience (List last or present position first)

List all experience, paid employment, volunteer work, or work in the US Armed Forces.

Date
From/To

Name of Employer

Telephone Number

Last Rate of Pay

Supervisor's Name and Title

State title and describe briefly the work you did

Reason for leaving

Date
From/To

Name of Employer

Telephone Number

Last Rate of Pay

Supervisor's Name and Title

State title and describe briefly the work you did

Reason for leaving

Date
From/To

Name of Employer

Telephone Number

Last Rate of Pay

Supervisor's Name and Title

State title and describe briefly the work you did

Reason for leaving

Date
From/To

Name of Employer

Telephone Number

Last Rate of Pay

Supervisor's Name and Title

State title and describe briefly the work you did

Reason for leaving

Professional Skills and Licensure

Typing       WPM     Office, hospital or industrial equipment skilled to operate:
Shorthand WPM    

Professional Licenses and/or Certifications:

        
                       Type                               State Issued                   Date Issued                     Expiration Date                      Number

        
                       Type                               State Issued                   Date Issued                     Expiration Date                      Number

        
                       Type                               State Issued                   Date Issued                     Expiration Date                      Number

Foreign Language Skills, Including Signing (Those which could be useful in the position(s) applied for).

Language 1 Speak   Fair
               Good
               Fluent		 Read   Fair
              Good
              Fluent		 Write   Fair
               Good
               Fluent
Language 2 Speak   Fair
               Good
               Fluent		 Read   Fair
              Good
              Fluent		 Write   Fair
               Good
               Fluent
References
List three references (not relatives or former employers)
 

Name

Address

Phone Number

Occupation
1. 
2. 
3. 

Special Skills and Qualifications

Indicate any special skills and qualifications which you have not had an opportunity to present elsewhere on this form.

Certification
 I certify that all statements made on this application are true and that I have not knowingly withheld any fact or circumstances which, if disclosed, affects my application unfavorably.
 I authorize the investigation of all statements contained in this application and the further investigation of any information required to determine my qualifications for the position(s) for which I am applying.
 I authorize former employers, schools and other references to release any information required to determine my qualifications for the position(s) for which I am applying and hereby release all individuals and organizations from any liability or damages on account of having furnished such information. I waive any right to receive written notice from this organization or former employers that such information has been released.
 I fully understand that the misrepresentation or omission of facts or circumstances will be sufficient for the cancellation of my consideration for employment or cause for dismissal if I have been employed.
 I understand that any offer for employment is contingent upon passing the Pre-Employment Drug Screen.
 I understand that a criminal background check will be required pre-employment.

Date:                   I Understand and concur with the above statements:  Yes  No

(Optional)  Paste text version of Resume (CV):


   

Do Not Write in This Space


Follow up action:  ________________________________________________________________________

Accepted for employment?  ___________  Starting rate:  __________  Starting date:  __________

Position:  _____________________________________  Department:  ____________________________

Interviewed by:  ________________________________________________  Date:  __________________

Interviewed by:  ________________________________________________  Date:  __________________

Approved by:  __________________________________________________  Date:  __________________

References checked by:  ________________________________________  Date:  __________________