Adams Health Network
 
Adams Health Employment Application

Below is the employment application for all Adams Health Network Divisions, including Adams Memorial Hospital, The Village of Heritage and Woodcrest of Decatur. Please select the division for which you wish to apply and continue with the application.

Personal Information
Applicant's Name:
Middle Name
 Last Name
  
Address
 City
 State
 Zip
Home Phone
 Email
    

Employment Desired
Position Desired
 Salary Expected
  
Are you available to work:
(check all that apply):
 Full Time Part Time  Temporary On-Call Overtime
First Shift Second Shift Third Shift

Are you able to perform the essential functions of the job for which you are applying with or without reasonable accommodation?
Yes No

On what date are you available to begin work?

List any days or times you are not available to work:
Are you on lay-off and subject to recall? Yes No

Have you filled out an application here before?

Yes
No

If yes, please give dates:

  

Have you been employed by AHN or its divisions before?

Yes
No

If yes, please give dates:

Reason for leaving:

Professional Licensing
Do you hold a professional registration, license, or certificate?
If Yes: List Type(s):
 State(s):
 License Numbers:
 Expiration Dates:
Have you ever had any professional registration, license, or certificate suspended or revoked?
Have you ever informally resolved any recommended or potential adverse action involving your professional registration, license, or certification?
Are any professional registration, licensure, or certification actions now pending against you?
Has any action been taken against you that excludes or has excluded you from participation in any federal or state government healthcare program, including but not limited to Medicare?

How did you hear about employment opportunities at AHN?
Are you a U.S. Citizen or an alien legally entitled to work in the position(s) for which you have applied? Yes No
If you are under 18, are you eligible for a work permit? Yes No

Education

Senior
High School

Name

City, State

Number of Years




Graduated?


Degree

College
or University

Name

City, State

Number of Years




Graduated?


Degree

Business
or Technical School

Name

City, State

Number of Years




Graduated?


Degree

Correspondence or Special School

Name

City, State

Number of Years




Graduated?


Degree
Please summarize special job-related skills and qualifications acquired from education, employment, volunteer work or military service.
List any specific skills you have that will be helpful in performing the responsibilities of the position(s) for which you are applying.

References

You must include at least two references who can comment on your work habits, responsibility, character and conduct.
  Name Address Telephone Number
Reference 1
Reference 2
Reference 3
Reference 4

Employment History
Employer 1
 Address
 City, State, Zip
 Phone
Beginning Date
 End Date
 Salary/Hourly Rate
 Type of Work Performed
Employer 2
 Address
 City, State, Zip
 Phone
Beginning Date
 End Date
 Salary/Hourly Rate
 Type of Work Performed
Employer 3
 Address
 City, State, Zip
 Phone
Beginning Date
 End Date
 Salary/Hourly Rate
 Type of Work Performed
Employer 4
 Address
 City, State, Zip
 Phone
Beginning Date
 End Date
 Salary/Hourly Rate
 Type of Work Performed
May we contact the employers listed above?



If no, indicate which one(s) you do not wish us to contact.

State the reason why you prefer that we do not contact the employer(s).
Have you ever worked under a different name?


If so, please list all names under which you have worked.
Have you ever been discharged or asked to resign from any position?


If yes, please state the employer and dates of employment.

Have you ever been disciplined at a place of employment?


 If yes, explain:
Which of the positions that you have held did you like best and why?
Which of the positions that you held did you like least and why?
Have you been convicted or plead guilty or no contest to a felony or misdemeanor other than a minor traffic violation?


If yes, please explain:

A conviction will not necessarily disqualify you from consideration. However, failure to fully disclose will result in denial or termination of employment.

Are any criminal charges pending against you?


   

Applicant's Statement

Please indicate that you have read and that you understand each paragraph of the Applicant’s Statement by clicking the radio button next to each statement.

1.

I certify that this application (including each attachment to this application, if any) was completed by me and that all entries on it and all information in it are true and complete to the best of my knowledge. In the event of employment, I understand that false, misleading, or omitted information in my application may result in discharge.

2.

I authorize investigation of all statements contained in this application for employment as may be helpful in arriving at an employment decision. In making this application for employment, I understand that an investigation may be made and information may be obtained through interviews with the personal references and past employers listed. This inquiry may include information as to my character, general reputation, and personal characteristics, as well as information about my work performance and workplace conduct. I consent to this investigation and to the consideration of any statements of references or former employers that are given in response to the inquiry.

3.

I hereby release all parties, including but not limited to AHN and its divisions, references, and previous employers, from any and all liability for any injury or damage that may result from their furnishing information to AHN and its divisions concerning me or any action AHN or its divisions takes on the basis of such information.

4.

I understand that, if I am offered a job, as a condition of beginning my employment I will be required to undergo a physical examination, Mantoux TB test, drug and/or alcohol screens at any time thereafter as AHN and its divisions deems necessary. I hereby authorize any doctor, hospital, clinic, laboratory or other medical facility to furnish any medical information with reference to me as may be necessary in conjunction with that examination and related consideration.

5.

I understand that, according to federal law, all individuals who are hired must, as a condition of employment, produce certain documentation to verify their identity and United States citizen status or, if aliens, their legal authorization to work in the United States. As a consequence, I understand that any offer of employment to me by AHN and its divisions is contingent upon my ability to produce the required documentation within the time period required by law.

6.

I understand that this application is not, and is not intended to be, a contract of employment and that any resulting employment relationship is for no fixed period time and is terminable at any time for any reason by AHN or its divisions, or by me. I further understand that statements which may be contained in policies, practices, handbooks, or other AHN material do not create any guarantee of employment and that AHN or its divisions has the right to modify, amend, or terminate policies, practices, benefit plans, or other programs within the limits and requirements imposed by law. I understand that no representative of AHN and its divisions, other than the Executive Director or designee, has the authority to enter into any agreement for a specific period time or to make any agreement contrary to the foregoing and that any such agreement must be in writing to be binding on AHN or its divisions.

7.

By clicking the submit button, I understand that it is the equivalent of a signature on a printed application.