Unity Medical Center Online Job Application

Unity Medical Center

An Equal Opportunity Employer

Application for Employment

Equal access to programs, services, and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.

Position(s) applied for

Date of application

Month

Day

Year

First Name

Last Name

Applicant ID#

Street Address

Street Address Line 2

City

State

Zip

Telephone #

Cellular/Other #

Referral Source (How did you hear about us)?

If you are under 18 and it is required, can you furnish a work permit?

Have you ever been employed here before?

Is this application a request for reemployment following an extended military leave of absence from this company? (If yes, additional information may be requested.)

Are you legally eligible for employment in this country?

Date available for work

Month

Day

Year

What is your desired salary range?

Type of employment desired:

Full-Time
Part-Time
Flex

Are you able to perform the "essential functions" of the job for which you are applying (with or without reasonable accommodation)? This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law.

Yes
No
Need more informaiton about the job's "essential functions" to respond

Driver's license number required if driving may be required in the job for which you are applying:

Driver's license State

Have you ever pleaded "guilty" or "no contest" to, or been convicted of, a crime? Answering "yes" to either part of this question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.

Employment History

Starting with your most recent employer, provide the following information.

Employer

Employer Phone

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Starting job title / final job title

Immediate supervisor and title (for most recent position held)

Why did you leave?

Summarize the type of work performed and job responsibilities.

May we contact for reference?

Yes
No
Later

Dates Employed & Pay Rate:

Employer #2

Employer Phone

Street Address

Street Address Line 2

City

State/Province

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Postal/Zip Code

Country

Starting job title/final job title

Immediate supervisor & title for most recent position held

Why did you leave

Summerize the type of work performed and job responsibilites

May we contact for reference?

Yes
No
Later

Dates Employed/Pay Rate

Employer #3

Street Address

Street Address Line 2

City

State/Province

Postal/Zip Code

Country

Starting job title/final job title

Immediate supervisor & title for most recent position held

Why did you leave?

Summerize the type of work performed and job responsibilities

May we contact for reference?

Yes
No
Later

Dates Employed/Pay Rate

Skills and Qualifications

Summarize any special training, skills, licenses and/or certificates that may assist you in performing the position for which you are applying:

Computer Skills (Include software title and years of experience in appropriate boxes.)

Word Processing

Spreadsheet

Presentation

E-mail

Internet

Other

Educational Background

Starting with your most recent school attended, provide the following information.

School

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Years Completed

Completed

Diploma
GED
Degree
Certification
Other

GPA Class Rank

Major/Minor

References

List names and telephone numbers of three business/work references who are NOT related to you and are NOT previous supervisors. If not applicable, list three school or personal references who are not related to you.

First Name

Last Name

Title

Relationship to You

Phone Number

# of Years Known

First Name

Last Name

Title

Relationship to You

Phone Number

# of Years Known

First Name

Last Name

Title

Relationship to You

Phone Number

# of Years Known

Applicant Statement

I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct.

I expressly authorize without reservation, the employer, it's representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representative, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.

I understand that this sapplication remains current for only 30 days. At the conclusion of that time, if I have not heard form the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and with or with out prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agrement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an appliant from consideration for employment on the basis of his or her sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status under applicable federal, state, or local law. This Company likewise does not tolerate harassment based on sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status. The Company takes all complaints of harassment seriously and all complaints will be investigated promptly and thoroughly.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Date

Month

Day

Year

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Online Application

Unity Medical Center

Application for Employment

Employment History

Skills and Qualifications

Educational Background

References

Applicant Statement

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

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