Chester River Health System
Career Opportunities - Online Application

Personal Information

Last Name:

First Name:
Middle Name:
Social Security Number:
Address1:
Address2:
City:
State:
Zip Code:
Home Phone:
Other number(s) where we may reach you:
Your Email Address:
Provide any other names you were employed under:
Have you previously worked for Kent & Queen Anne's Hospital, Chester River Home Care & Hospice, or Magnolia Hall?

Yes
No

If yes, please specify a location:


If yes,from to

If under age 18, can you provide required proof of your eligibility to work? Yes
No

Employment Information

Position you are applying for
Job Interest: (Check all that apply)
Full Time

Part Time

 Weekend Alternative
Per Diem

Relief

 Temporary
Shift Availability:
(Check all that apply)		 Day
Evening
Night
Can you work shift rotations? Yes
 No
Can you work holidays? Yes
No
Can you work weekends? Yes
 No
Are there any days and/or hours you will NOT be willing to work?
Salary Requirements:

Education

High School

School Name:
City:
State:
Highest Grade Completed:
Did you graduate? Yes
No
If no, have you received a GED? Yes
No

College, University, Nursing School

School Name:
City:
State:
Please select the number of years you attended:
1 2
3 4
More then 4

Did you graduate? Yes
No
Major or type of progam?
Other education or training?

Professional Registration/License
If the position for which you are applying requires a
professional license or certification, complete this section.

Registration/License Number:
State:
Expiration Date:

Employment Experience

Please list your present or most recent job first.  Include any job-related military service assignments and volunteer activities.  You may exclude organizations which indicate race, color, religion, gender, national origin, disability or other protected status.  Complete all requested information.
Employer: *
Address: *
Telephone Number:
Job Title:
Dates Employed (mm/dd/yy): from to
Supervisor:
Hourly Rate: / hour
Type of Work Performed:
Reason for Leaving:

Job Responsibilities/Comments:

Employer: *
Address: *
Telephone Number:
Job Title:
Dates Employed (mm/dd/yy): from to
Supervisor:
Hourly Rate: / hour
Type of Work Performed:

Reason for Leaving:



Job Responsibilities/Comments:

Employer: *
Address: *
Telephone Number:
Job Title:
Dates Employed (mm/dd/yy): from to
Supervisor:
Hourly Rate: / hour
Type of Work Performed:

Reason for Leaving:

Job Responsibilities/Comments:

Employer: *
Address: *
Telephone Number:
Job Title:
Dates Employed (mm/dd/yy): from to
Supervisor:
Hourly Rate: / hour
Type of Work Performed:

Reason for Leaving:



Job Responsibilities/Comments:

Special Skills & Qualifications

Summarize special job-related skills and qualifications acquired from employment or other experience.  Include typing speed, familiarity with medical terminology, technical, clinical, or special skills and list office machines you can operate.

References

Please include persons other than relatives and employers.   You may include teachers, pastors, and community leaders.
Name:
Address:
Telephone Number:
Occupation:
Years Known:
Name:
Address:
Telephone Number:
Occupation:
Years Known:
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status? (Proof of citizenship or immigration will be required upon hiring.)

Yes                 No
Have you been convicted of a crime other than a minor motor vehicle offense?

Yes                  No
If yes, please explain: 
(A "Yes" answer is not necessarily a disqualification.)

Are you able to perform the essential functions of the job for which you have applied with or without reasonable accommodations?

Yes                 No

Consent & Release

I certify that the answers given in this application are complete and true.  I hereby authorize persons, schools, my current employer (if applicable) and previous employers and organizations named in this application (and accompanying resume, if any) to provide Chester River Health System with any relevant information regarding an employment decision, and I release all such persons from any liability regarding the provision or use of such information.

I agree as a condition of my employment that I may be transferred to another department or shift if required by staffing levels.  I understand that I may terminate my employment at will and that the Health System retains a similar right. 

Employment is contingent upon successfully completing a physical examination, which includes a drug screening conducted by Kent & Queen Anne's Hospital staff.

Name of Applicant:
Date:

Under Maryland law an employer may not require or demand any applicant for employment or prospective employment to submit to or take a polygraph, lie detector, or similar test or examination as a condition of employment or continued employment.  Any employer who violates this provision is guilty of a misdemeanor and subject to a fine not to exceed $100.
Name of Applicant:
Date:

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

Applicants are considered for all positions without regard to race, color, religion, sex, age, marital or veteran status, mental or physical disabilities, or any other legally protected status.

Employment applications are valid for 30 days.