Chester River Health System Career Opportunities

Chester River Health System
Career Opportunities - Printable 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:	_____________________________________ _____________________________________
Provide any other names you were employed under.	_____________________________________ _____________________________________
Have you previously worked for Kent & Queen Anne's Hospital or Chester River Home Care & Hospice? Provide dates.	_____________________________________ _____________________________________
If under age 18, can you provide required proof of your eligibility to work?	Yes No
Employment Information
Job Interest:	Full Time	Part Time	Weekend Alternative
	Per Diem	Temporary	Relief
Shift Availability:	Day Evening Night
Can you work shift rotations?	Yes No
Can you work holidays?	Yes No
Can you work weekends?	Yes No
Salary Requirements:	________________________
Education
High School
School Name:	_____________________________________
City:	_____________________________________
State:	_____________________________________
Highest Grade Completed:	_____________________________________
Did you graduate?	Yes No
Receive GED?	Yes No
College, University, Nursing School
School Name:	_____________________________________
City:	_____________________________________
State:	_____________________________________
Degree Received:	_____________________________________
In what field?	_____________________________________
Other education or training?	_____________________________________ _____________________________________ _____________________________________ _____________________________________
Professional Registration/License
Registration/License Number:	_____________________________________
State:	_____________________________________
Expiration Date:	_____________________________________
Employment Experience Please list your current 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:	_____________________________________
Any Additional 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:	_____________________________________
Any Additional 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:	_____________________________________
Any Additional 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:	_____________________________________
Any Additional 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? (A "yes" answer is not necessarily a disqualification.)	Yes No
If yes, please explain: __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________
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.
Signature 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.
Signature of Applicant:	_____________________________________
Date:	_____________________________________
WE ARE AN EQUAL OPPORTUNITY EMPLOYER Applicants are considered for all positions without regard to race, color, religion, sex, origin, age, marital or veteran status, mental or physical disabilities, or any other legally protected status. We reserve the right to require all applicants for employment to undergo a drug screening test as part of the employment process. Employment applications are valid for thirty (30) days.

Back to
Careers Page