Career Application- Certified Surgical Tech Step 1 of 4 25% Name First Last Date Are you at least 18 years old?--YesNoPrimary PhoneSecondary PhonePresent Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email Are you currently credentialed for the position for which you are applying?--YesNoType of Position Full Time Part Time PRN Temporary Shift Weekend Day Night Evening Rotation Salary Requirement ($)If overtime is required periodically, does this pose a problem for you?--YesNoDate Available for Work Are you legally authorized to work in the U.S.?--YesNoHave you ever worked for Lincoln County Health System?--YesNoAre you related to another facility employee?--YesNoHow did you learn about this position? College Placement Office Social Media Our Website If Employee Referral, Advertisement, or Other please check this box and explain below: Please ExplainAre you able to perform the essential, job related functions of the position for which you are applying with or without reasonable accommodations?--YesNoHave you ever been convicted of a crime?--YesNoIf yes, give date, place and nature of each such conviction.Are you currently excluded from participation in any federally funded healthcare program - including Medicare and Medicaid - and are you aware of any potential exclusion from a federally funded health program?--YesNoEducation History High School School NameCityStateLast Year Attended9101112Graduated / GED?--YesNo College College NameCityStateLast Year Attended1234Graduated?--YesNoDegree College #2 (if applicable) College NameCityStateLast Year Attended1234Graduated?--YesNoDegree Graduate School School NameCityStateLast Year Attended1234Graduated?--YesNoDegreeLicensing and CertificationsList any professional licenses, registration or certification you possess (Include Driver's License, if applicable)License/Registration/CertificationNumberState IssuedExpiration Date License/Registration/CertificationNumberState IssuedExpiration Date License/Registration/CertificationNumberState IssuedExpiration Date License/Registration/CertificationNumberState IssuedExpiration Date License/Registration/CertificationNumberState IssuedExpiration Date Does the position you are applying for require you to drive? If yes, answer additional three questions.--YesNo1. Do you have a current and valid driver's license?--YesNo2. Have you ever been denied a driver's license, or convicted of a moving traffic offense, including, but not limited to driving while intoxicated or reckless driving?--YesNoIf yes, please provide details:3. Do you have proof of automobile insurance?--YesNoClerical or other skills applicable to the position for which you are applyingCheck all additional skills that apply E-mail, Internet Microsoft Applications Excel, Word, and PowerPoint Other List other skills Work History Current or Most Recent Date From Date To Company NameJob TitleSalary ($)Immediate Supervisor First Last AddressPhoneMay we contact them?--YesNoName while employedNature of DutiesReason for leavingNumber of Hrs/WeekPRNFull-TimePart-TimePart-Time Hours Previous Date From Date To Company NameJob TitleSalary ($)Immediate Supervisor First Last AddressPhoneMay we contact them?--YesNoName while employedNature of dutiesReason for leavingNumber of Hrs/WeekPRNFull-TimePart-TimePart-Time Hours Previous Date From Date To Company NameJob TitleSalary ($)Immediate Supervisor First Last AddressPhoneMay we contact them?--YesNoName while employedNature of dutiesReason for leavingNumber of Hrs/WeekPRNFull-TimePart-TimePart-Time Hours Previous Date From Date To Company NameJob TitleSalary ($)Immediate Supervisor First Last AddressPhoneMay we contact them?--YesNoName while employedNature of dutiesReason for leavingNumber of Hrs/WeekPRNFull-TimePart-TimePart-Time HoursProfessional References (Other than Relatives)Give references who have good knowledge of your workName First Last PositionRelationshipPhoneEmail Name First Last PositionRelationshipPhoneEmail Name First Last PositionRelationshipPhoneEmail Name First Last PositionRelationshipPhoneEmail Upload ResumePlease review and acknowledge that you understand the following. In submitting this application for employment: I certify that the information in this application is true and complete for all practical purposes. It may be verified by the facility. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the facility is relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse. I authorize Lincoln County Health System to thoroughly investigate my references, work record, education and other matters related to my suitability for employment, (e.g., motor vehicle operator records, criminal records, school records, licensure records, etc. ) and further authorize the references I have listed to disclose to the company and all letters, reports, and other information related to my work records, without giving me prior notice of such disclosure. In addition, I release Lincoln County Health System, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure. I UNDERSTAND AND AGREE THAT ANY POLICIES WHICH I MAY RECEIVE WILL NOT CONSTITUTE AN EMPLOYMENT CONTRACT. Compliance with this facility's Substance Abuse Policy is a condition of employment. This hospital requires that every newly hired employee be free of drug abuse. I understand and acknowledge that I may be required to submit to a physical examination, including drug testing. I hereby authorize the release of the results of such an examination to Lincoln County Health System for their use in evaluating my suitability for employment. Further, I release the examining facility and Lincoln County Health System from any and all liability, and from any damage that may result from the release of such information. Each offer of employment is contingent upon successfully completing a urinalysis test/screen for drugs in accordance with hospital policy. I UNDERSTAND AND AGREE THAT IF I AM OFFERED EMPLOYMENT BY THE FACILITY, MY EMPLOYMENT WILL BE FOR NO DEFINITE TERM AND THAT EITHER I, OR THE FACILITY WILL HAVE THE RIGHT TO TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, I ALSO UNDERSTAND THAT THIS STATUS CAN ONLY BE ALTERED BY A WRITTEN CONTRACT OF EMPLOYMENT WHICH IS SPECIFIC AS TO ALL MATERIAL TERMS AND IS SIGNED BY ME AND THE ADMINISTRATOR OF THE FACILITY. Release: I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my license status and my license history.I have read and understand these conditions of employment.* Yes Applicant's full nameDate Prepared By clicking the "Next: Release Authorization" button below, I agree that all of the preceding questions are answered truthfully and to the best of my abilities. Release AuthorizationList maiden names and/or other names used.Other NamesFull NameDate I understand that by checking the following box and typing my name into the name field above, this document is as valid as if I have signed it.* I agree Disclosure Regarding Background Investigation & Authorization.Full Name*Date* DISCLOSURE AND ACKNOWLEDGEMENT (IMPORTANT — PLEASE READ CAREFULLY BEFORE SIGNING ACKNOWLEDGEMENT) I understand that by checking the following box and typing my name into the name field above, this document is as valid as if I have signed it. Lincoln County Health System may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, criminal and civil litigation history information, motor vehicle records (“driving records”), sex offender status, education verification, professional license, drug testing, Social Security Verification, employment history, and personal history (only once a conditional offer of employment has been made). You have the right, upon written request made within a reasonable time after receipt of this notice, to request whether a consumer report has been run about you, and the nature and scope of any investigative consumer report, and request a copy of your report. ACKNOWLEDGEMENT AND AUTHORIZATION I acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. In consideration of my application, I authorize Lincoln County Health System by and through to verify all data given by me on my application, related papers or oral interviews. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, any employers, agencies, personal references, law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau or insurance company and other persons with whom I am acquainted to answer all questions and release all information including but not limited to my employment record, character, reputation, ability, education, military service, credit history and other applicable reports and/or furnish any and all background information requested by ESS, or another outside organization acting on behalf of Lincoln County Health System. Furthermore, I release all agencies, bureaus, employers, information service organizations and individuals or companies named above from all liabilities or damages that might result from information provided in good faith. I state that the information provided by me on my application is accurate and I agree that if any information is found to be false at any time, my application may be discarded or my employment terminated. I understand that the information requested below regarding sex and date-of-birth are for the sole purpose of gathering the above information accurately and will not be used to discriminate against me in violation of the law. I agree that a facsimile (“fax”), electronic or photographic copy of the Authorization shall be as valid as the original.PhoneThis field is for validation purposes and should be left unchanged.