Information Driver
Resume:
APPLICATION FOR EMPLOYMENT
Daughters of Charity Ministries offers equal employment opportunities to all persons without regard to race, religion, age, sex, color, national origin, ancestry, disability, uniformed service, union or other legally protected class or status recognized by federal, state or local law. No question on this application is intended to secure information that may be used to discriminate. Therefore, please limit responses to questions asked and do not volunteer information regarding any of the above listed classifications, like participation or membership in professional, civic, political, volunteer or other groups, committees or organizations.
The Daughters of Charity Ministries complies with the American With Disabilities Act and considers reasonable accommodation measures that may be necessary for eligible applicants/associates to perform the essential functions of a position.
Answer all questions fully, honestly and completely. Do not leave any questions blank. If a question does not apply, print “N/A” which means “not applicable.” Failure to follow these instructions will be considered when making employment decisions. Any false, misleading or incomplete answers may result in immediate denial or termination of employment.
This application will only be used for the position indicated by you. To be considered for another position, you must reapply. This form does not obligate Daughters of Charity Ministries in any way.
PERSONAL INFORMATION
Last Name:
First Name:
Middle:
Other Names Used for Employment Purposes:
Present Address:
City, State, Zip
Home Phone:
Business Phone:
Alternate Phone:
Have you ever been convicted or pled guilty or no contest to a felony, misdemeanor or any other offense other than a minor traffic violation? Yes No If Yes, please explain below.
Are any felony criminal charges now pending against you that are not yet resolved? Yes No If yes, explain below.
Have you ever been excluded, suspended or otherwise ineligible for participation in Federal programs or have a controlling interest in any entity that has been so excluded or suspended? Yes No If yes, explain below.
Are you legally authorized to work in the United States? Yes No
Military Status:
Branch:
Rank:
Type of Discharge:
Specialty:
A conviction will not necessarily disqualify you from consideration. However, failure to disclose will result in immediate denial or termination of employment.
POSITION INFORMATION
Date:
Position Applied For:
Position Type:
Full Time Part Time
Temporary Per Diem
Have you ever applied for employment with Daughters of Charity? Yes No When?
Salary Desired:
Where did you learn about this position?
CareerBuilder Agency School Website Other
Associate Referral Please list Associate Name:
Please give names of any family and friends currently or formerly employed by Daughters of Charity Ministries:
Are you able to perform the essential functions of the position for which you are applying either with or without reasonable accommodations?
Yes No If no, please describe the function that cannot be performed.
Have you ever been employed by Ascension Health or one of the Ministries? If yes, please provide the name of the organization and dates of employment. Yes No
EDUCATIONAL BACKGROUND
Name and Location of High School Attended:
Did You Graduate:
Highest Grade Completed:
Name and Location of College Attended:
Did You Graduate:
Highest Grade Completed:
Name and Location of College Attended:
Did You Graduate:
Highest Grade Completed:
Please list Major and Minor Courses of Study:
Postgraduate work: Yes No Degree:
Describe any other specialized or professional training (such as business, technical or nursing school); include study courses through Armed Forces institute and public or private employment. State whether degree or certificate was received.
Other Applicable Skills:
EMPLOYMENT HISTORY (Please start with your current or most recent employer. Please complete all information even if a resume is attached. Do not use “see resume.”)
Name of Current or Most Recent Employer:
Position Title:
Name and Title of Immediate Supervisor:
Date of Employment (to/from):
Starting Salary:
Ending Salary:
Bonus Eligibility:
Phone Number for Company or Supervisor:
Reason for Leaving:
Description of Duties:
May we contact this employer for a reference? Yes No
Name of Previous Employer:
Position Title:
Name and Title of Immediate Supervisor:
Date of Employment (to/from):
Starting Salary:
Ending Salary:
Bonus Eligibility:
Phone Number for Company or Supervisor:
Reason for Leaving:
Description of Duties:
May we contact this employer for a reference? Yes No
Name of Previous Employer:
Position Title:
Name and Title of Immediate Supervisor:
Date of Employment (to/from):
Starting Salary:
Ending Salary:
Bonus Eligibility:
Phone Number for Company or Supervisor:
Reason for Leaving:
Description of Duties:
May we contact this employer for a reference? Yes No
Name of Previous Employer:
Position Title:
Name and Title of Immediate Supervisor:
Date of Employment (to/from):
Starting Salary:
Ending Salary:
Bonus Eligibility:
Phone Number for Company or Supervisor:
Reason for Leaving:
Description of Duties:
May we contact this employer for a reference? Yes No
LICENSE
Do you have a Driver’s License? Yes No
Driver’s License Number:
State of Issue:
License Type:
Expiration Date:
PROFESSIONAL LICENSES/CERTIFICATIONS
Please provide information regarding any professional licensure or registration.
Profession:
Identification Number:
State:
Effective Date:
Expiration Date:
Profession:
Identification Number:
State:
Effective Date:
Expiration Date:
Profession:
Identification Number:
State:
Effective Date:
Expiration Date:
Have you ever had any professional registration, licensure, or certification suspended or revoked; ever informally resolved and recommendation or potential adverse (negative) action involving your registration, licensure, or certification or have any actions pending against you? Yes No If yes, please explain.
REFERENCES (Please list names and telephone numbers of at least three business/work references (non-relatives)
Name:
Telephone Number:
Relationship:
Name:
Telephone Number:
Relationship:
Name:
Telephone Number:
Relationship:
AFFIDAVIT: I certify the answers I provided on this employment application are true and correct. I agree that Daughters of Charity Ministries shall not be liable in any respect if my application is rejected or my employment is terminated because of false statements, answers, or omissions made by me in this application. I authorize Daughters of Charity Ministries to make inquiries it may deem necessary and to contact persons and agencies, in connection with my application for employment. I authorize and instruct any person or agency to participate in and make inquiries at the request of Daughters of Charity Ministries to compile information, and to furnish information obtained as a result of such inquiries. I release all parties from any and all liability resulting from supplying such information.
If you are offered employment with Daughters of Charity Ministries, at all times, you will be, and shall remain, an employee at will to the extent allowed by law. I understand that any offer of employment, is contingent on the satisfactory results of a pre-employment background verification, which may include a test to detect the presence of drugs or alcohol. I authorize the release and disclosure of the results to Daughters of Charity Ministries. I understand that the results of the pre-employment background verification may be disclosed to members of the management staff within the company and/or others who may have a legitimate interest in such information.
I acknowledge that Daughters of Charity Ministries is an at-will employer and that neither Daughters of Charity Ministries nor I are bound to an employment contract or a commitment for employment for any definite period of time.
I HAVE CAREFULLY READ OVER THIS ENTIRE APPLICATION FOR EMPLOYMENT AND UNDERSTAND FULLY ALL OF ITS CONTENTS AND INSTRUCTIONS.
SIGNATURE:
DATE:
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