Apply Online - Orleans Community Health

Step 1 of 7

General Information
Date of Application*
MM slash DD slash YYYY
Position Applying For*
Salary Desired*
How Did You Learn About Us?*
Name*
First Middle Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Email*

If you are under 18 years of age, can you provide required proof of your eligibility to work?
Have you ever been employed by Medina Memorial Hospital?*
Have you ever been employed by Orchard Manor?*
Provide employment date*
Position Held*
Are you currently employed?*
May we contact your present employer?*

If your former employment references, education, or military service are under a name other than indicated on front of application, please indicate:
First Middle Last
Are you authorized to work in the United States?*
Proof of authorization to work in the United States will be required upon employment.
On what date would you be available for work?*
Are you available to work:*
- Full Time
- Part Time
- Per Diem
- Shift Work
Have you ever had disciplinary action taken against any license, or are you currently the subject of a report or investigation?*
Please Explain*
Have you ever been convicted of a criminal act?**
please explain and include type of crime(s), date(s), and location of offense*
* An applicant may not be denied employment because of a conviction record unless there is a direct relationship between the offense and the job or unless hiring would be an unreasonable risk

Elementary & Jr. High
School Name
Course
Number of Years Completed
Degree / Diploma
High School
School Name
Course
Number of Years Completed
Degree / Diploma
College Technical or Other
School Name
Course
Number of Years Completed
Degree / Diploma
List any professional certificates or licenses held : ( type, number, expiration date, and State)
Note to Applicants:
Do not answer this question unless you have been informed about the job requirements for the job for which you are applying.
Are you capable of performing in a reasonable manner the activities involved in the job or occupation for which you have applied? A description for the activities involved has been presented to you to read.

EMPLOYMENT RECORD
(Start with your present or last job. Include any job related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status)
Job #1
Organization Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Salary range
Position & duties
Supervisor’s Name
Phone
Reason for leaving
Job #2
Organization Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Salary range
Position & duties
Supervisor’s Name
Phone
Reason for leaving
Job #3
Organization Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Salary range
Position & duties
Supervisor’s Name
Phone
Reason for leaving
Explain periods of unemployment:
Do you have any relatives who are employed by this organization?*
Please specify*

References
Reference #1
Name
Address
Fax
Phone
Reference #2
Name
Address
Fax
Phone
Reference #3
Name
Address
Fax
Phone

Consent
As a condition of employment I understand that I may be required to take and pass a drug and or alcohol screen in any or all of the following circumstances:
Pre-employment - For cause - Random selection
I UNDERSTAND THAT EMERGENCY CONDITIONS MAY REQUIRE ME TO TEMPORARILY WORK SHIFTS OTHER THAN THE ONE FOR WHICH I AM APPLYING AND AGREE TO SUCH SCHEDULING CHANGE AS DIRECTED BY MY DEPARTMENT HEAD OR ADMINISTRATOR OF THIS INSTITUTION.
I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information.
I understand that, if I become employed, I will be an employee at will, which means that I or my Employer may terminate my employment at any time for any reason, with or without cause, and with or without notice. I understand that I will be required to follow the Employer’s personnel policies and rules. I have fully, completely, and accurately completed this application form. I understand that I may be terminated for any misstatement or omission of fact appearing on this application form.
I further understand that this institution follows the “fair employment practice code” and there is no discrimination in the hiring of individuals based on sexual orientation, sex, race, religion, age, or physical or mental handicap unrelated to ability to perform the work required.
Agreement*
- I agree
Name
This field is for validation purposes and should be left unchanged.

General Info

Step 1 of 7

General Information

Elementary & Jr. High

High School

College Technical or Other

Note to Applicants:

EMPLOYMENT RECORD

Job #1

Job #2

Job #3

References

Reference #1

Reference #2

Reference #3

Consent