High School Supervisor
Resume:
Application for Employment
Catholic Health East is committed to equal employment opportunity for all qualified individuals and will not discriminate in
its hiring practices due to race, color, creed, religion, marital status, sex, ancestry, age, disability, national origin, status as
a veteran or any other characteristic protected by law.
Any individual who because of a disability needs accommodation or assistance in completing this application, or at any
time during the application process, should contact the HR Department.
PLEASE PRINT
PERSONAL INFORMATION
Name: (Ms., Mrs., Mr., Dr.) First Middle Last
Are there any other names by which you may have been known?
Complete Mailing Address: Home Phone
Work Phone
Cell Phone
Position Applying For: Social Security Number:
Can you perform the essential functions of the position for which you are applying, with or without accommodation as
described in the advertisement, job posting and/or job description?
Yes No
Have you ever been convicted of a crime, excluding misdemeanors?
Yes No
(Please note that all circumstances will be considered and that the conviction of a crime does not constitute an automatic bar to employment.)
If Yes, please describe in full.
How did you hear about this position? (Advertisement: list newspaper/magazine; E-advertisement: list site; Catholic
Health East web site; Employee referral: list name)
Desired Salary Range: $ to $
EDUCATION
High School Technical School College Graduate School
School Name & Location
Years Completed (Circle) 9 10 11 12 1 2 1 2 3 4 1 2 3 4
Diploma Degree (Circle) Yes No Yes No Yes No Yes No
Major Course(s) of Study
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EMPLOYMENT
Have you been employed by Catholic Health East or a Catholic Health East Regional Health Corporation?
Yes No
If yes, what were the dates of employment? _______________ to ________________
List all employers since the completion of high school. Attach additional sheets as necessary. Please provide
an explanation of all gaps in employment.
Current Employer
Company Name Supervisor’s Name
Address Phone Number
Employment Dates: From ____/____/____ To ____/____/____
Starting Pay: $
Reason for Leaving:
Ending Pay $
May we contact this employer? Yes No
Previous Employer
Company Name Supervisor’s Name
Address Phone Number
Employment Dates: From ____/____/____ To ____/____/____
Starting Pay: $
Reason for Leaving:
Ending Pay $
Previous Employer
Company Name Supervisor’s Name
Address Phone Number
Employment Dates: From ____/____/____ To ____/____/____
Starting Pay: $
Reason for Leaving:
Ending Pay $
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REFERENCES
List the names and contact information for three people, excluding relatives, who have knowledge of your professional
experience and ability. At least one name, preferably two, should be that of a former or current supervisor.
Name: Years Known:
Home Phone: Work Phone:
Title:
Employer:
Relationship:
For CHE Use:
Name: Years Known:
Home Phone: Work Phone:
Title:
Employer:
Relationship:
For CHE Use:
Name: Years Known:
Home Phone: Work Phone:
Title:
Employer:
Relationship:
For CHE Use:
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IMPORTANT: PLEASE READ THE FOLLOWING PRIOR TO SIGNING
I certify that the information contained in this application for employment
is true, correct and complete and I hereby grant Catholic Health East (hereinafter
known as CHE) permission to verify the information contained herein. I
understand that the giving of false information or the failure to give complete
information requested herein shall constitute grounds, among others, for rejection
of my application or my immediate termination in the event that I am hired. I
hereby grant CHE permission to verify the information provided herein and
recognize that my employment is conditional upon the receipt of satisfactory
recommendations from former employers and references. I understand, further,
that an offer of employment, if made, may be contingent upon my taking and
passing a pre-employment physical examination and drug screen and recognize
that I may be required to take a physical examination and drug tests as a
condition of my continued employment.
An offer of employment is conditional on the satisfactory proof of identity
and legal authority to work in the United States as required by the Immigration
and Naturalization Services Employment Eligibility Verification form (Form I-9).
I understand that this application for employment and any other
documents issued by CHE are not contracts of employment and recognize that I
am free to terminate my employment upon reasonable notice and that I may be
terminated by CHE at any time and for any reason. I further understand that no
employee or representative of CHE other than the President, has the authority to
enter into an agreement for employment for any specified period of time and
recognize that any oral or written statements to the contrary are hereby expressly
disavowed and should not be relied upon.
Authorized Signature of Applicant Date
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Contact this candidate