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HIND GENERAL HOSPITAL LLC
Application for Employment
First Name:
   
Middle Name:
   
Last Name:
   
Social Security No: - -
   
Address (line 1):
   
Address (line 2):
   
City:
   
State:
   
Zip Code:
   
Telephone Number: - -
   
Cell Phone Number: - -
   
Position Applied For:
   
Salary Expected:
   
Are you at least 18 years of age: Yes No
 
Are you eligible to work in the U.S: Yes No
All applicants tentatively selected for a position will be required to submit to a urinalysis to screen for illegal drug use prior to employment.
       
Shifts you will consider:   Rotating Days Evenings Nights
       
Days available:   Mon Tues Wed Thurs Fri Sat
Sun
       
Date Available to Start Employment:   - -
       
Have you ever applied to this Organization before?   Yes No
       
If Yes when:   - -
       
List qualifications or skills that you possess that would be beneficial to this position (computer skills, insurance billing etc.):  
       
Have the essential functions of the job been explained to you?   Yes No  
       
Do you understand the essential job functions?   Yes No  
       
Are you able to perform the essential job functions with or without reasonable accommodations for any disability?   Yes No  
EDUCATION: List high school, trade school, college, graduate or other schools attended.
High School: Name of the School or University City Zip Code State
Number of Years Credit Hours Graduate? Degree Earned
 
Trade School: Name of the School or University City Zip Code State
Number of Years Credit Hours Graduate? Degree Earned
 
College: Name of the School or University City Zip Code State
Number of Years Credit Hours Graduate? Degree Earned
 
Graduate Or Other Schools: Name of the School or University City Zip Code State
Number of Years Credit Hours Graduate? Degree Earned
 
PROFESSIONAL LICENSE/REGISTRATION/CERTIFICATION
Type Of License/Registration/ Certification State Number Expiration
Date
If you do not have a license, have you applied for one?                               Yes No N/A
     
If an examination is required, when are you scheduled to take the examination?   - -
     
If not licensed in Indiana, have you applied for reciprocity?   Yes No N/A
     
To Has anyone ever complained to a licensing agency or the Board about you?   Yes No
     
If yes please explain in detail:  
     
If no, do you have a legal right to reside permanently and work in the United States?   Yes No
     
If not licensed in Indiana, have you applied for reciprocity?   Yes No
     
 
Have you ever had a claim against your license/registration or has it ever been revoked, suspended or restricted? If yes please explain in detail:  
 
REFERENCES:
Name Address, City and State Phone Number
 
EMPLOYMENT HISTORY:
CURRENT/PAST EMPLOYMENT (Starting with the most recent)
From Mo/Yr
To Mo/Yr		 Name & Address of Employer Supervisor


Position Salary Reason for Leaving
 
From Mo/Yr
To Mo/Yr		 Name & Address of Employer Supervisor


Position Salary Reason for Leaving
 
From Mo/Yr
To Mo/Yr		 Name & Address of Employer Supervisor


Position Salary Reason for Leaving
 
From Mo/Yr
To Mo/Yr		 Name & Address of Employer Supervisor


Position Salary Reason for Leaving
 
From Mo/Yr
To Mo/Yr		 Name & Address of Employer Supervisor


Position Salary Reason for Leaving
 
May the hospital contact your current employer?  Yes No
       

List any other employment not listed above including any military time:
   

       
Have you ever been convicted of any criminal offense (excluding misdemeanor traffic offenses)? Yes No
       
Have you ever been charged with malpractice, breech of duty, or failure to meet the requirements of your job duties in either or both a court of administrative proceeding, under federal, state or local laws, ordinances or regulations? Yes No
       
Has the Secretary of Health and Human Services found you to be in default of scholarship obligations or loans in connection with health professions education made or secured, in whole or in part by the Secretary of Health and Human Services? Yes No
       
Have you ever had any adverse legal actions imposed by Medicare or any other legal agency or program against you? Yes No
       
Have you ever signed a non-compliance agreement?   Yes No
       

If your answers to any of the foregoing five questions are yes, please provide all facts and circumstances, including but not limited to dates of the events and names, addresses, and telephone numbers of persons who have information of relevance:
       
I acknowledge and agree that all the information provided by me in support of my application is true and complete. I authorize Hind General Hospital, LLC to verify any of the information concerning my employment, education, or credit history with appropriate persons, entities, or governmental agencies, and I hereby authorize them to release such information, as Hind General Hospital requires, including the entirety of my prior employment record, without any obligation to give me notice or disclosure. I further authorize Hind General Hospital to release any information requested by any of my prospective or subsequent employers, without any obligation to give me notice of such disclosure. I hereby release Hind General Hospital and all other persons or entities from any liability whatsoever which arises as a result of such inquiries and disclosures. I agree that any false or incomplete information provided by me in support of my application will subject me to discharge at any time during the period of my employment. If hired, I understand that employment at Hind General Hospital is at-will in nature, meaning that the Hospital or I may terminate the relationship at any time, with or without notice, and I understand that this arrangement may only be altered in writing which is signed by the Executive Director of the Hospital after approval by the Board of Directors. I also understand that if offered employment, I may be required to obtain a pre-employment physical and/ or tests to detect either or both illegal drug or alcohol use, which tests may be administered during my employment on either or both random or reasonable suspicion basis.
Hind General Hospital does not permit private practice arrangements, unless prior approval is obtained in a written agreement signed by the Executive Director, upon approval of the Board of Directors.
  
 
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