GRAFTON CITY HOSPITAL

GRAFTON, WEST VIRGINIA

ATTENTION: JOB APPLICANT

We are pleased to receive your employment application. You are applying for a position as an employee-at-will. This means that if you are hired, you may leave your employment with Grafton City Hospital at any time, and Grafton City Hospital may terminate your employment at any time. You will not have a contract of employment, and nothing in Grafton City Hospital's written policies, handbooks, or other documents will create any contractual obligations on the part of the Hospital. As an Equal Opportunity Employer, we will review and consider your application as follows:

COMPLETE APPLICATION AND OTHER FORMS IN FULL

It is essential that you complete the attached forms thoroughly and accurately. If more space is needed, attach additional sheets or include your resume. A complete application enables us to accurately access your qualifications for the position for which you have applied. An incomplete application may be disqualified from further consideration.

HOW YOUR APPLICATION IS PROCESSED

Your completed application form will be given to the appropriate Employment Representative for review and evaluation. Although Grafton City Hospital is not obligated to interview you by acceptance of your application, our screening process is designed to ensure a professional evaluation of your qualifications. Because of the large number of applications we receive, it is not possible to respond personally to each inquiry.

PRE-EMPLOYMENT TESTING

Clerical applicants and others in selected occupational groups may be scheduled for pre-employment testing.

HOW INTERVIEWS AND REFERRALS ARE SCHEDULED

If you are declared one of the most qualified applicants to compete for the position for which you have applied, the Employment Representative will refer you to the Department Manager for further consideration. The Department Manager and Administrator will make the final hiring decision by choosing the best qualified candidate in his/her judgment without regard to race, sex, age, handicap, veteran status, religion, sexual orientation, color or national origin, as defined by law.

ARBITRATION

If any controversy shall arise between the parties in the performance, interpretation, and application of this Application For Employment, either party may serve upon the other a written notice stating that such party desires to have the controversy reviewed by an arbitrator, who shall be representative of a firm specializing or having substantial experience in the hospital industry. If the parties cannot agree, within fifteen (15) days from the service of such notice upon the other party on the selection of such an arbitrator, that individual shall be selected or designated by the American Arbitration Association upon the written request of either party hereto. Arbitration of such controversy, disagreement or dispute shall be conducted in accordance with the rules then in force of the American Arbitration Association, and the decision and award of the arbitrators so selected shall be binding upon both parties hereto.

APPLICATION STATUS

A completed application is required to be submitted with respect to each vacancy for which you apply. All information on the form MUST be current. This will ensure that your application for employment receives a complete and thorough review. Due to the large number of employment applications received, it is not possible to keep all applicants constantly informed of the status of their applications. However, applicants referred to departmental hiring authorities for interviews will be apprised of the hiring decision. Our policy is to hold applications/resumes for a six-month period.

I have received the above information. I have had an opportunity to review and understand the above information. I have been given the opportunity to ask questions, and I agree to be bond by the above terms.

Date: Signature of Applicant: __________________________________________

GRAFTON CITY HOSPITAL

500 MARKET STREET, GRAFTON, WV 26354

APPLICATION FOR EMPLOYMENT

Grafton City Hospital is an Equal Employment Opportunity employer and does not discriminate on the basis of race, sex, age, handicap, veteran status, religion, sexual orientation, color or national origin. Your application will be processed in accordance with all the provisions set forth in the regulations which are available for your review in the Personnel/Payroll Department. APPLICATION MUST BE PRINTED OR TYPED. RESUMES AND ADDITIONAL INFORMATION MAY BE ATTACHED.

PERSONAL INFORMATION:

_______________________________________

(Last Name) (First) (Middle)

___________________________________________

(Street or RFD Address) (Apt. #)

___________________________________________

(City) (State) (Zip Code)

___________________________________________

(Home Telephone No.) (Work Telephone No.)

_____________________ _ _ _ - _ _ - _ _ _

(Maiden Name) (Social Security #)

Are you legally entitled to work in the United States?

YES: _____ NO: ______

(Proof of your work status may be required if hired.)

Are you a previous employee of Grafton City Hospital? YES: _____ NO: ______

Date: From: ____________ To: _______________

Last Position Held: __________________________

Department: ________________________________

Under What Last Name: ______________________

Have you been interviewed by Grafton City Hospital within the last six months:

YES: _____ NO: ______

If YES, approximate date:______________________

POSITION APPLYING FOR:

_________________________________________________________________________________________________________________________________

Willing to work:

( ) Full Time ( ) Temporary

( ) Part Time ( ) Shift or Rotating

Date available for employment: ________________

EDUCATION: (Name of High School)

______________________________________

(Full Name and Address of School)

______________________________________

______________________________________

Check training completed in high school, business college, college or through prior work experience:

( ) Typing ( ) Word Processing

( ) Shorthand ( ) Data Processing

( ) Bookkeeping ( ) Accounting

( ) ( )

Trade, Technical or Industrial School:

______________________________________

(Full Name and Address of School)

______________________________________

______________________________________

List any major courses or Diploma/Certificate received:

______________________________________

______________________________________

College/University Training: (Use additional sheets if necessary.)

______________________________________

(Name of Institution)

______________________________________

(City) (State) (Zip Code)

______________________________________

(Major)

______________________________________

(Degree Received)

Honors, Licenses, Certificates, Registrations and Professional Organizations that do not reflect sex, racial, ethnic, age or religious background:

______________________________________

______________________________________

RECORD OF MILITARY SERVICE:

Service Branch: _____________________________

Job Duties In Military Service:

______________________________________________________________________________________

EMPLOYMENT RECORD: Start with the most recent first. (Use additional sheets if necessary.)

___________________________________________

(Employer's Name)

___________________________________________

(Street Address)

___________________________________________

(City) (State) (Zip Code)

___________________________________________

(Supervisor's Name) (Telephone Number)

May we check references?

YES: NO: $ (Final Salary)

FROM: TO:

(Employment Dates)

___________________________________________ (Reason For Leaving)

Description Of Duties:

*******************************************

___________________________________________

(Employer's Name)

___________________________________________

(Street Address)

___________________________________________

(City) (State) (Zip Code)

___________________________________________

(Supervisor's Name) (Telephone Number)

May we check references?

YES: NO: $ (Final Salary)

FROM: TO:

(Employment Dates)

___________________________________________ (Reason For Leaving)

Description Of Duties:

__________________________________________

(Employer's Name)

___________________________________________

(Street Address)

___________________________________________

(City) (State) (Zip Code)

___________________________________________

(Supervisor's Name) (Telephone Number)

May we check references?

YES: NO: $ (Final Salary)

FROM: TO:

(Employment Dates)

___________________________________________ (Reason For Leaving)

Description Of Duties:

If any, summarize additional employment or other factors supporting your possible employment by Grafton City Hospital:

___________________________________________

___________________________________________

___________________________________________

*******************************************

PROFESSIONAL AND CHARACTER REFERENCES:

Name: ____________________________________

Address: ___________________________________

_____________________________ Phone: _______

Occupation: ________________________________

Name: ____________________________________

Address: ___________________________________

_____________________________ Phone: _______

Occupation: ________________________________

Name: ____________________________________

Address: ___________________________________

_____________________________ Phone: _______

Occupation: ________________________________

*******************************************

I hereby certify that my answers to the above questions are true, complete and correct. I understand that if I am employed, false answers on this application may be grounds for immediate dismissal. I further understand that dependent on bona fide occupational qualifications, authorized security checks and a consent to a criminal background check may be made on my application and that my answers to the above questions are subject to verification.

Date: _______ Sigature: ___________________

GRAFTON CITY HOSPITAL

PRE-EMPLOYMENT INFORMATION FORM

(Please answer all questions. If more space is needed, attach additional sheets.)

1. Have you ever been discharged or forced to resign from employment?

YES: NO: If YES, give details including name or employer(s):

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

2. Have you ever been convicted of a crime or, within two years, been incarcerated for a misdemeanor conviction?

YES: NO: If YES, give details:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

3. I’ve held employment outside of West Virginia within the past five (5) years: Yes___ No___

If “Yes”, please list the county(s)/state(s) of your employment: ________________________________

____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

SPECIAL NOTE: A conviction record is not necessarily a bar to employment at Grafton City Hospital. A number of factors will be taken into account during the application assessment process including, but not limited to, age at time of the offense, number, recentness, seriousness and nature of the violation(s), relationship of the offense to the job sought, rehabilitation, prior work history and other job-related criteria.

CERTIFICATION STATEMENT: (Read this statement carefully before signing.)

I hereby certify that my answers to the above questions are true, complete and correct. I understand that if I am employed, false answers on this statement may be grounds for immediate dismissal. I further understand that dependent on bona fide occupational qualifications, authorized security checks may be made on my application and that my answers to the above questions are subject to verification. I have given my consent to a criminal background check and an investigation into other job-related qualifications so noted on my application for employment.

(Date) (Signature Of Applicant)