Oswego Health: Job Application

Oswego Hospital • 110 W. 6th Street • Oswego, NY • 13126 • 315-349-5553 (Including Behavioral Services)
Springside at Seneca Hill • 10 Co. Rte 45A • Oswego, NY • 13126 • 315-343-5658
The Manor at Seneca Hill • 20 Manor Dr. • Oswego, NY • 13126 • 315-349-5300

Personal Information
Position Applying For *
2nd Choice
Date Available *
Status *	Full-Time Part-Time Per Diem Temporary
Shift Preference *	Days Evenings Nights
Are you willing to rotate shifts? *
	Yes No
Are you willing to work weekends? *
	Yes No
Are you 18 years of age or older? *
	Yes No
Do you have transportation to work? *
	Yes No
Last Name *
First Name *
Middle Initial
Street Address *
City *
State *
Zip Code *
Home Phone
Alternate Phone
E-mail Address
Social Security Number *	- -
How were you referred to Oswego Health? *	Walk-in Advertisement - Specify: Job Fair - Specify: Other - Specify:
Have you ever worked for Oswego Health? *
	Yes No
When?
Position?
Except for minor traffic violations or violations as a Youthful Offender;
Are you now under charges for violation of law? *
	Yes No
Were you convicted of any violation of law? *
	Yes No
If you answered "Yes" to either of the above, give particulars and disposition of each charge: Charges and/or convictions will not necessarily exclude you from employment.
Hire is subject to verification that applicant meets legal age and U.S. work permit requirements. Have you the legal right to work in the United States? *
	Yes No
U.S. Military Status
Are you a veteran? *	Yes No
Length of service:	to
Are you presently a member of the Reserve or National Guard? *
	Yes No
Education

	Name, City, State	Degree / Diploma Type	Date
High School
College
College
Graduate School
Business, Trade or Other

Employment History
Skills	Keyboard - Words Per Minute PC Skills - Specify PC Skills
Please list any other special training, skill and experience:

Most recent/current Employer	Position	Address	Phone
Supervisor	Salary	Dates of Employment	Reason for Leaving
Job Duties
Employer	Position	Address	Phone
Supervisor	Salary	Dates of Employment	Reason for Leaving
Job Duties
Employer	Position	Address	Phone
Supervisor	Salary	Dates of Employment	Reason for Leaving
Job Duties

References - Give the names of professional references, not related to you, who may be contacted.
Name	Address	Phone	Business	Years Acquainted

May we request references from:
Your current employer? *	Yes No
Your former employer(s)? *	Yes No
Résumé	(Optional)

I understand, if employed, I will be subject to an introductory period and continued employment will be contingent on satisfactory completion of that introductory period. I further understand and agree that, if hired, my employment is for no definite period and may be terminated at any time without notice, with or without cause.

I understand that any false statement made by me on this application may prevent my employment or may be cause for discharge if hired.

I further understand that I must meet the health standards required by the Department of Health as a condition of initial and continued employment which will be determined by a physical examination by Employee Health Services.

It is the policy of Oswego Health to recruit, hire, and promote qualified applicants without regard to race, color, religion, sex, age, national origin, handicap, veteran status or other areas covered by federal, state, or local fair employment laws and regulations.

I agree * I do not agree

I have applied for a position at the above indicated facility. I hereby authorize the release of any educational information and/or any information regarding my job performance to Oswego Health and its affiliates. My records are listed under the following name(s): *

I agree * I do not agree

This application is considered current for 1 year only. At the end of this period, if you are still interested in employment, it will be necessary for you to reapply by completing a new application.