LTAC HOSPITAL CORPORATION

APPLICATION FOR EMPLOYMENT

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

INSTRUCTIONS: Complete all the necessary information. You may be asked to provide additional information on another form. This application will be kept on file. It is to your advantage to periodically check to keep it current and active. Be sure to sign and date the application.

Position(s) Applied for:	Date of Application(mm/dd/yr)
Last Name	First Name	Middle Initial

Street Address

Apt. No

City

State

Telephone Number(s)

Social Security Number

Are you available to work:

FULL-TIME

PART-TIME

SHIFT WORK

TEMPORARY

DAYS & HOURS

Are you legally eligible for employment in the United States?	Yes	NO
Are you of legal age to work in the United States?
If you are under 18 years of age, can you provide required proof of our eligibility to work?
Have you ever filed an application with us before? If yes, give dates:
Have you ever been employed with us before? If yes, give dates:
Are you currently on “lay-off” status and subject to recall?
Can you travel if a job requires it? If so, how far? ___________miles
Have you ever been notified that you are excluded from participating in a Medicare provided program?
If yes, please explain:
Have you been convicted of a felony within the last seven (7) years?
If yes, please explain:

EDUCATIONAL BACKGROUND

Name of School	Address of School	Course of Study	Years Completed	Diploma/Degree
Elementary School
High School
College
Graduate/Professional
Others (Specify)

INDICATE ANY FOREIGN LANGUAGES YOU CAN SPEAK, READ, AND/OR WRITE

	FLUENT	GOOD	FAIR
SPEAK
READ
WRITE

Describe any specialized training, apprenticeship, skills, and extra-curricular activities you have been involved in:

Describe any job-related training received in the military:

List membership in professional, trade, business, or civic activities and offices held. (Exclude memberships which would reveal gender, race, national origin, age, ancestry, sexual orientation, disability, or any other protected status)

EMPLOYMENT EXPERIENCE

Start with your most recent job. Include any job-related military service assignments and volunteer activities (Exclude employment experiences which would reveal gender, race, national origin, age, ancestry, sexual orientation, disability, or any other protected status)
1

Employer's Name & Address	Date Employed From: To:	Work Performed
Telephone #	Hourly Rate/Salary Starting Final
Job Title:	Supervisor:	Do you want us to contact this Employer?
Reason for Leaving:

Employer's Name & Address	Date Employed From: To:	Work Performed
Telephone #	Hourly Rate/Salary Starting Final
Job Title:	Supervisor:	Do you want us to contact this Employer?
Reason for Leaving:

Employer's Name & Address	Date Employed From: To:	Work Performed
Telephone #	Hourly Rate/Salary Starting Final
Job Title:	Supervisor:	Do you want us to contact this Employer?
Reason for Leaving:

Employer's Name & Address	Date Employed From: To:	Work Performed
Telephone #	Hourly Rate/Salary Starting Final
Job Title:	Supervisor:	Do you want us to contact this Employer?
Reason for Leaving:

PROFESSIONAL REFERENCES

Please provide a list of professional references: (Do not include family members, friends, etc) A separate reference report is available to document reference information.
1

Name of Reference and Job Title

Telephone Number (day)

Telephone Number (alternate)

Address

Name of Reference and Job Title

Telephone Number (day)

Telephone Number (alternate)

Address

Name of Reference and Job Title

Telephone Number (day)

Telephone Number (alternate)

Address

APPLICANT’S STATEMENT

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed forty five (45) days. Any application wishing to be considered for employment beyond this time period should inquire as to weather or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicant law, and employment relationship with this organization is of an “at will” nature, which means that the employee may resign at any time and LTAC Hospital Corporation may discharge the employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document, or by conduct, unless such changes are specifically acknowledged in writing by an authorized executive of LTAC Hospital Corporation.

I also understand that employment with LTAC Hospital Corporation and its’ subsidiaries or divisions may be contingent upon proof of a physical exam.

In the event of employment, I understand that false or misleading information given in my application or interviews(s) may result in immediate discharge. I understand, also, that I am required to abide by all the rules and regulations set forth by LTAC Hospital Corporation and its’ subsidiaries and divisions.

I certify that I am not and never have been excluded from any federally funded healthcare program, including Medicare or Medicaid, and, if hired, I agree to immediately disclose any threatened or proposed exclusion.

The undersigned indicates that I have read the job description for the position and may carry out the duties and responsibilities stated in herein.

______________________ _________________________

Signature of Applicant Date (month/day/year)