GENERAL - PERSONAL INFORMATION

COLLEGE HOSPITALS

OFFICE

USE ONLY

College Hospital Cerritos

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

Cerritos, California 90703

***/***-**** ** ***/826-2140

College Hospital Costa Mesa

301 Victoria Street,

Costa Mesa, California 92627

949/642-2734

APPLICATION FOR EMPLOYMENT

AN EQUAL OPPORTUNITY EMPLOYER

WHAT IS THE BEST TIME

TO CONTACT BY TELEPHONE?

PLEASE TYPE / PRINT / EMAIL

Last Name First Middle Home Telephone

Home Address (Street & Number) City State Zip Code Previous Residences in the United States Cell Phone Email Address Are you age 18 or over?

Yes No

Friends or Relatives employed by this Hospital

(First Choice) (Second Choice) Minimum Earnings Required Date Available for Work

Full Time

Part Time

Per Diem

On Call

Drop-in Ad Website School

Shift Preferred - 1st Choice 2nd Choice 3rd Choice Have you ever worked at a College Health Enterprises entity before? Where? When? Under what name? Are you able to perform the essential functions of the position for which you are applying, either with or without reasonable accommodations? Yes No

NAME

POSITION DESIRED

College Medical Center

2776 Pacific Ave.,

Long Beach, California 90806

562/997-2241 or 562/997-2000

Other Names Under Which You Have Worked

How Did You

Become

Aware Of The

Position?

If necessary, please describe what type(s) of reasonable accommodations are needed: EDUCATION

NAME AND LOCATION OF SCHOOLS

High School Last Attended

College

or

University

Name

City State

Name

City State

Graduate

School

Name

City State

Business or

Vocational

Name

City State

Other

GRAD.

Yes No Major Field of Study

LICENSING

BCLS for Healthcare Providers Yes No Expires

MISCELLANEOUS SKILLS OR ACTIVITIES

MEMBERSHIP IN PROFESSIONAL ORGANIZATIONS

REFERENCES (Other than relatives)

GIVE THREE REFERENCES WHO HAVE KNOWN YOU DURING THE PAST FIVE OR MORE YEARS. Name Position Address (Include City/State)

Phone

Work / Home

Number of

years known

1.

2.

3.

Degree

Number of

Years

List special language skills, scholarships or other significant activities ( Please omit those indicating race, color, sex, national origin, ancestry, age, the existence of a disability, or any other protected characteristics). Identify each license or certification held, include serial numbers and expiration dates. PAST EMPLOYMENT

May we contact your present employer: Yes No

Company Name Telephone Number

Street City State Zip Code

What did you like most about the work?

What did you like least?

Reason for leaving

From:

To:

mo yr

Type of Business

$

Starting Final

Account for the past ten (10) years. Include periods of unemployment, self-employment, schooling or military service. List present (or most recent) position first. Please include any other name under which such records may appear. Attach supplement sheet if more space needed. Duties and Responsibilities?

Monthly Salary:

$

Title Supervisor

Company Name Telephone Number

Street City State Zip Code

What did you like most about the work?

What did you like least?

Reason for leaving

From:

To:

mo yr

Type of Business

$

Starting Final

Duties and Responsibilities?

Monthly Salary:

$

Title Supervisor

Company Name Telephone Number

Street City State Zip Code

What did you like most about the work?

What did you like least?

Reason for leaving

From:

To:

mo yr

Type of Business

$

Starting Final

Duties and Responsibilities?

Monthly Salary:

$

Title Supervisor

Company Name Telephone Number

Street City State Zip Code

What did you like most about the work?

What did you like least?

Reason for leaving

From:

To:

mo yr

Type of Business

$

Starting Final

Duties and Responsibilities?

Monthly Salary:

$

Title Supervisor

SECURITY/RIGHT TO WORK

Yes No

Yes No

(Please exclude misdemeanor convictions for marijuana-related offences more than two years old; convictions that have been sealed, expunged, or legally eradicated; and misdemeanor convictions for which probation was successfully completed or otherwise discharged and the case was judicially dismissed. If yes, briefly describe the nature of crime(s), the date and place of conviction(s), and the legal disposition of the case(s). The Hospital will not deny employment to any applicant solely because he or she has been convicted of a crime. Each case will be evaluated based on it's own facts and merits. Yes No

Yes No

If you answered yes to either of the two questions above, please explain the date of the arrest, the facts involved, and the court, if any, in which the matter was resolved. OTHER INFORMATION

Please indicate additional information relevant to your application which may be helpful to us. I hereby certify that the information contained in this application form is true and correct to the best of my knowledge and agree to have any of the statements checked by the Hospital unless I have indicated to the contrary. I authorize the references listed above, as well as all other individuals whom the Hospital contacts, to provide the Hospital any and all information concerning my previous employment and any other pertinent information that they may have. Further, I release all parties and persons from any and all liability for any damages that may result from furnishing such information to the Hospital as well as from any use or disclosure of such information by the Hospital or any of it's agents, employees, or representatives. I understand that any misrepresentation, falsification, or material omission of information on this application may result in my failure to receive an offer or, if I am hired, my immediate dismissal from employment.

In consideration of my employment, I agree to conform to the rules and standards of the Hospital. I further agree that, unless modified by a collective bargaining agreement or other written agreement signed by the president of the Hospital, my employment, compensation, and benefits can be modified or terminated with or without cause, and with or without notice, at any time, either at my option or at the option of the Hospital. I understand that no employee or representative of the Hospital, other than its president, has the authority to enter into any agreement for employment for any specified period of time, or to make any express or implied agreement contrary to the foregoing. Further, the president of the Hospital may not alter the at-will nature of the employment relationship or enter into any employment agreement for a specified time unless the president and I or my representative both sign a written agreement that clearly and expressly specified the intent to do so. I agree that this shall constitute a final and fully binding integrated agreement with respect to the at-will nature of my employment relationship and that there are no oral or collateral agreements regarding this issue. I also understand that all offers of employment are conditioned on: (1) the Hospital's receipt of satisfactory responses to reference requests and the provision of satisfactory proof of an applicant's identity and legal authority to work in the United States; (2) applicant's satisfactory completion of a post-offer medical examination and drug/alcohol screening; (3) applicant's agreement to and execution of the Hospital's Mutual Arbitration Policy and Employee Agreement to Arbitrate; and (4) applicant's agreement to abide by and execution of acknowledgment of the Hospital's employee handbook and employment policies. SIGNATURE DATE

College Hospital 6/2014

Have you ever been convicted of a crime?

Do you have the legal right to work and be employed in the U.S.? (Proof of identity and legal authority to work in the U.S. is a condition of employment.) If you are seeking a position with regular access to patients, have you ever been arrested for a sex-related offense specified in Section 290 of the California Penal Code? If you are seeking a position that would present you with access to drugs and medications, have you ever been arrested for any drug related offense specified in Health and Safety Code Section 11590? COLLEGE HOSPITAL

Voluntary Self-Identification Form

College Hospital is subject to certain governmental recordkeeping and reporting requirements of the administration of civil rights laws and regulations. In order to comply with these laws, College Hospital invites employees to voluntarily self-identify their race and ethnicity. Submission of this Information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information will be kept confidential and will only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify a specific individual. This form will be kept separate from your personnel file. I am:

If you checked "Not Hispanic or Latino", please check one of the following racial/ethnic categories: Hispanic or Latino: a person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race. Not Hispanic or Latino

American Indian or Alaska Native: a person having origins in any of the original peoples of North, South and Central America, and who maintain cultural identification through tribal affiliation or community attachment.

Asian: a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Black or African American: a person having origins in any of the Black racial groups of Africa. Native Hawaiian or Other Pacific Islander: a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White: a person having origins in any of the original peoples of Europe, the Middle East or North Africa.

Two or More: a person who identifies with more than one of the above five races. I am: Female Male

Name: Date:

Position:

College Hospital 6/2014

Contact this candidate