PRE-ADMISSION FORM
* Required PERSONAL DATA Name * Phone Present Address How long there? Previous Address How long there? School District Social Security No. Other names by which you have been known (including maiden name) Are you a US citizen? If no, type of visa Date of entry Position desired Pay expected Date Available How long do you plan to work here? Do you want to work: Full-Time Part-Time If part-time, state reason Which shift do you prefer? Day Evening Nights Weekend Will you work other shift? Yes No Who or what prompted you to contact Wayne HealthCare? Have you previously been interviewed by us? Employed by us? Have you ever been convicted of a felony? Yes No Have you ever been excluded from participation in any federal heathcare program or non procurement program? Yes No List relatives working for Wayne HealthCare Name Relationship Department Military service dates, from to Rank at discharge In case of emergency, notify Relationship Address Phone Professional licenses or registration Professional organizations you belong to Additional information you may wish to add to describe your full qualifications EDUCATION SCHOOL SCHOOL, ADDRESS, AND PHONE ATTENDED Mo Yr. DID YOU GRADUATE DEGREE AND MAJOR HIGH SCHOOL From To Yes No COLLEGE From To Yes No GRADUATE STUDY From To Yes No Other Training or Skills From To Yes No WORK EXPERIENCE DATES Mo. Yr. COMPANY, ADDRESS, AND PHONE A. Your Position B. Supervisor REASON FOR LEAVING From To A. B. From To A. B. From To A. B. From To A. B. TO BE COMPLETED BY APPLICANTS FOR CLERICAL POSITIONS Can you type? Yes No W.P.M Can you write shorthand? Yes No W.P.M Key Punch Training? Yes No Other business machines? Yes No May we contact your present employer? Upload Resume (.pdf or .doc file format only) If Wayne HealthCare learns during the review of an applicant's qualifications that the applicant otherwise failed to follow ethical or compliance standards of prior employer, Wayne HealthCare may refuse to hire applicant as an employee. Wayne HealthCare does not retain or hire individuals on the cumulative sanctions list of persons excluded from participation in federal health care programs as prepared by the Office of the Inspector General of the U.S. Department of Health and Human Services. Wayne HealthCare queries the cumulative sanctions report at www.os.dhhs.gov/progorg/org prior to an individual's employment and on a periodic basis for all employees. Wayne HealthCare does not retain or hire individuals on the List of Parties Excluded From Federal Procurement and Non Procurement Programs. Wayne HealthCare queries the exclusion list at www.amet.gov/epls prior to an individual's employment and on a periodic basis for all employees. Wayne HealthCare may employ an applicant conditionally prior to obtaining the results of any of the records checks listed above, Wayne HealthCare terminates such conditional employment upon receiving results of check which shows that the applicant is currently excluded from participation in any federal health care program or participation on federal procurement and non-procurement programs. The facts set forth above in my application for employment are true and correct. I authorize the investigation of all information contained in this form to determine my suitability for employment at Wayne HealthCare. I understand that misrepresentation or omission of facts called for may be cause for dismissal. I also understand that regular employment depends on satisfactory replies from my references, background investigation and successful completion of the probationary period. Date * Signature of Applicant (by checking this box I agree to the above statements) This application will be kept on file for a period of one(1)year Powered By ChronoForms - ChronoEngine.com
* Required
List relatives working for Wayne HealthCare
If Wayne HealthCare learns during the review of an applicant's qualifications that the applicant otherwise failed to follow ethical or compliance standards of prior employer, Wayne HealthCare may refuse to hire applicant as an employee.
Wayne HealthCare does not retain or hire individuals on the cumulative sanctions list of persons excluded from participation in federal health care programs as prepared by the Office of the Inspector General of the U.S. Department of Health and Human Services. Wayne HealthCare queries the cumulative sanctions report at www.os.dhhs.gov/progorg/org prior to an individual's employment and on a periodic basis for all employees.
Wayne HealthCare does not retain or hire individuals on the List of Parties Excluded From Federal Procurement and Non Procurement Programs. Wayne HealthCare queries the exclusion list at www.amet.gov/epls prior to an individual's employment and on a periodic basis for all employees.
Wayne HealthCare may employ an applicant conditionally prior to obtaining the results of any of the records checks listed above, Wayne HealthCare terminates such conditional employment upon receiving results of check which shows that the applicant is currently excluded from participation in any federal health care program or participation on federal procurement and non-procurement programs.
The facts set forth above in my application for employment are true and correct. I authorize the investigation of all information contained in this form to determine my suitability for employment at Wayne HealthCare. I understand that misrepresentation or omission of facts called for may be cause for dismissal. I also understand that regular employment depends on satisfactory replies from my references, background investigation and successful completion of the probationary period.
This application will be kept on file for a period of one(1)year
