O'Connor Hospital Contact Information
Switchboard: (607) 746-0300
Employment Application
NAME
last *
first *
middle *
social security number *
home phone *
message phone *
ADDRESS INFORMATION
complete address *
how long?
complete previous address
email address *
O'CONNOR WORK HISTORY (IF APPLICABLE)
have you ever worked here? *
Yes No
department
position
dates
what source led you to apply at o'connor? *
names of relatives employeed here
primary position *
locations (delhi)
list specific skills
salary desired *
minimum salary you would consider *
are you able to be legally employeed by this country? * yes no
what type of position are you seeking? * full time part time temporary
are you able to meet the essential functions of the position? yes no (If applying for a specific position.)
HOURS AVAILABLE
su
m
t
w
th
f
sa
from
to
veteran? * yes no
type of discharge honorable dishonorable n/a
List name and address of each school
Degree
Course Studied
high school *
college
other
additional information that may help us in placing you in a position at o'connor hospital
EMPLOYMENT REFERENCE (A)
Salary
Employeed
name of employer *
start *
final *
from (mo/yr) *
to (mo/yr) *
position *
supervisors name *
phone *
address *
description of duties *
reason for leaving *
EMPLOYMENT REFERENCE (B)
EMPLOYMENT REFERENCE (C)
name of employer
start
final
from (mo/yr)
to (mo/yr)
supervisors name
phone
address
description of duties
reason for leaving
EMPLOYMENT REFERENCE (D)
EMPLOYMENT REFERENCE (E)
have you ever been convicted of a crime (misdemeanor or felony)? yes no
If so, in the box below, please provide the following information: date and place of conviction(s), nature of conviction(s), penalty imposed (imprisonment, fine, etc.), and the circumstances of the incident(s) leading to the conviction(s). Note: conviction of a crime does not necessarily disqualify you from employment.
Work Reference
Phone With Area Code
Email Address
1
*
2
3
I hereby authorize the organizations named above to provide O'Connor Hospital with any information and opinions concerning my educational background, previous work experience and work-related qualifications, behavior, and character. I understand that the information and opinions disclosed by my former educators and employers will be used by O'Connor Hospital to evaluate my suitability for employment, and may include both favorable and unfavorable material. I hereby release each of my former educators and employers, and their respective agents and employees, from any and all claims and liabilities related to the information and opinions they provide to O'Connor Hospital.
O'Connor Hospital * may may not contact my current employer.
Optional Gender and Ethnic Information
O'Connor Hospital is a federal contractor and is required to maintain information on ethnicity, gender, and veteran status. This information is for record keeping purposes only and will not be used for employment consideration. As a federal contractor, O'Connor Hospital is subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended, which required government contractors to take affirmative action to employ and advance in employment qualified veterans of the Vietnam era. If you are a veteran and would like to be considered under the affirmative action program, please tell us. You may inform us of your desire to benefit under the program at this time and/or at any time in the future.
Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. Information you submit about your veteran status will be kept confidential. The information provided will be used only in ways that are not inconsistent with the Vietnam Era Veterans' Readjustment Act of 1974, as amended.
Gender Male Female No Answer
Ethnicity/Race Native American Black Asian or Pacific Islander Hispanic White Other
Signature
The above information is true to the best of my knowledge. I understand that any misrepresentation may be cause for rejection of the application or dismissal.
I understand that my employment with O'Connor Hospital is subject to a background check, including a criminal background check; passing a physical examination provided by O'Connor Hospital; and verification of my references, my licensure/registration/certification (if applicable), and my authorization to work in the United States.
