Employment Application

ROLLING PLAINS MEMORIAL HOSPITAL

    Address
    Positions Applying For:
     
     
    Will you work:
    • Are you legally eligible for employment in the United States?
    • (Proof of identity and employment eligibility will be required upon employment)
    Have you ever worked for RPMH before?
    • What was your reason for leaving?
    Reason for wanting to return?
    Have you been discharged or asked to resign in the last five years? If yes, why?
    Have you ever been convicted of a felony under any name?
    • if yes, explain
    * Criminal convictions are not an absolute bar to employment, but will be considered in relation to specific job requirements.

    EDUCATION:
    Yes
    No     		Yes  
    No   
    1
    2
    3
    4     		Yes
    No
    1
    2
    3
    4     		Yes
    No
    1
    2
    3
    4     		Yes
    No
    Other: Business College, Technical School and other special courses
    SPECIAL SKILLS:
    • Other Skills:
    PROFESSIONAL LICENSURES AND CERTIFICATION:
    If Licensed, Registered or Certified Type
    PREVIOUS EXPERIENCE:

    CURRENT OR MOST RECENT

    Job Title & Duties:
    Reason for leaving

    1ST PREVIOUS

    Job Title & Duties:
    Reason for leaving

    2nd PREVIOUS

    Job Title & Duties:
    Reason for leaving

    3rd PREVIOUS

    Job Title & Duties:
    Reason for leaving
    Please explain any gaps in employment dates
    MILITARY SERVICE:
    RECRUITMENT INFORMATION:
    Please check reason(s) for choosing Rolling Plains Memorial Hospital
    • IN CASE OF EMERGENCY: Whom shall we notify?

     

    All qualified applicants will receive consideration for employment without regard to race, creed, religion, color, gender, age, national origin or disability. I understand that my application will be active for one year from date of completion. If not hired during this period of time, I must complete another application.

    I understand RPMH is required by the Texas Department of Aging and Disability Services (DADS) to search the Nurse Aide and the Employee Misconduct Registry. If I am listed on the registry as having abused, neglected or exploited a resident or a consumer of a facility or an individual receiving services from an agency, it will result in the rejection of my application or the termination of my employment.

    I understand RPMH conducts criminal history investigations as a part of the hiring process, and checks applicant records for convictions, guilty pleas or nolo contendere, probation and deferred adjudication. Criminal history investigations are required by law for some positions, and are considered a business necessity for other positions. Your signature on this application constitutes your consent for RPMH to perform a criminal history investigation to verify the information you provide below. Any false information, misrepresentations or omissions regarding criminal history may result in the rejection of your application or the termination of your employment. I release RPMH from any and all potential liability resulting from the criminal history investigation and any release of information learned, including any damage to my reputation.

    I authorize any and all investigations deemed necessary by RPMH to verify the information contained herein. I authorize RPMH to investigate statements and references and release RPMH from any/all liability resulting from such investigation. I also release my previous employers to provide Rolling Plains Memorial Hospital with any information regarding my previous employment which may be necessary for the selection process. I understand that Rolling Plains Memorial Hospital will not inform me of the details of any references received from my previous employers. Previous employers are hereby relieved of any liability for references that they reasonably believe to be factual and pertinent.

    I understand that I must pass a Drug and Alcohol Screen to be hired by RPMH. I further understand that, if hired, I may have to take a drug and/or alcohol screen during my employment, and that if the screen is positive, I will be terminated.

    I understand that I may not be hired or, may be terminated immediately, if any of the aforementioned checks result in unfavorable information.

    I understand and agree that, if I am employed, my employment with Rolling Plains Memorial Hospital will be as an "at will" employee and that my employment may be terminated by me or RPMH at any time with or without notice and with or without cause. I understand and agree that my "at will" employment cannot be modified except by a special written agreement executed by me and the Administrator of RPMH.

    I understand and agree that any and all conditions of my employment can be changed or terminated at any time with or without notice.

    I understand that any false statements or any omission of information appearing on this or any other employment form will be sufficient reason not to hire me, and if discovered after my employment, will result in termination. I understand that if I add any additional information not asked for in the application, the additional information will be disregarded.

    I understand that if I have pending debts owed to RPMH, I must make arrangements for payment of the debt to be hired by RPMH.

    I declare that my answers to the questions in this application are true to the best of my knowledge and belief