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EMPLOYMENT APPLICATION
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First Name
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M.I.
Last Name
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Mailing Address
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Physical Address
City
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State
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Zip Code
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Home Phone
Business Phone
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Email
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Desired Salary
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How Can We Contact You?
Education / Job Related Training & Course Work
High School, College, University, or Professional School (An Official Transcript may be required) Vocational, Trade, Government, Business Armed Forces, etc.
Name of School
Location
Credit Hours Earned
Start Date
Month
Day
Year
End Date
Month
Day
Year
Dates of Attendance
Quarter
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1000
.
Semester
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1000
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Course of Study
Type of Degree
Did you graduate?
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Certificate/Transcript
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Education 2
High School, College, University, or Professional School (An Official Transcript may be required) Vocational, Trade, Government, Business Armed Forces, etc.
2. Name of School
2. Location
Credit Hours Earned
2. Start Date
Month
Day
Year
2. End Date
Month
Day
Year
Dates of Attendance
2. Quarter
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2. Semester
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1000
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2. Course of Study
2. Type of Degree
2. Did you graduate?
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Education 3
High School, College, University, or Professional School (An Official Transcript may be required) Vocational, Trade, Government, Business Armed Forces, etc.
3. Name of School
3. Location
Credit Hours Earned
3. Start Date
Month
Day
Year
3. End Date
Month
Day
Year
Dates of Attendance
3. Quarter
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0
to
1000
.
3. Semester
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0
to
1000
.
3. Course of Study
3. Type of Degree
3. Did you graduate?
Yes
No
Education / Job Related Training & Course Work
Licensure, Registration, Certification (Examples: RN, LPN, PES, CPA, etc.)
License or Certification
License #
License Date
Month
Day
Year
License Expiration Date
Month
Day
Year
License Certificate
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License 2
2. License or Certification
2. License #
2. License Date
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Day
Year
2. License Expiration Date
Month
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Year
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License 3
3. License or Certification
3. License #
3. License Date
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Day
Year
3. License Expiration Date
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Year
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Licensure, Registration, Certification (Examples: RN, LPN, PES, CPA, etc.)
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Periods of Employment
Describe your work experience in detail, beginning with your current or most recent job. Include military services (include rank) and job related or volunteer work, if applicable. Indicate the number of employees supervised. ALL information in this section must be completed. Resume must be attached.
Resume
(Required)
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Name of Present or Last Employer
Address
Phone
Your Job Title
Supervisor’s Name
From
Month
Day
Year
To
Month
Day
Year
Hours per Week
No. of Employees Supervised
Duties and Responsibilities
May we contact your previous supervisor for a reference?
Yes
No
Starting Salary
Ending Salary
Reason for Leaving
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Period of Employment 2
2. Name of Present or Last Employer
2. Address
2. Phone
2. Your Job Title
2. Supervisor’s Name
2. From
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Day
Year
2. To
Month
Day
Year
2. Hours per Week
2. No. of Employees Supervised
2. Duties and Responsibilities
2. May we contact your previous supervisor for a reference?
Yes
No
2. Starting Salary
2. Ending Salary
2. Reason for Leaving
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Period of Employment 3
3. Name of Present or Last Employer
3. Address
3. Phone
3. Your Job Title
3. Supervisor’s Name
3. From
Month
Day
Year
3. To
Month
Day
Year
3. Hours per Week
3. No. of Employees Supervised
3. Duties and Responsibilities
3. May we contact your previous supervisor for a reference?
Yes
No
3. Starting Salary
3. Ending Salary
3. Reason for Leaving
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Periods of Employment
Knowledge / Skill / Abilities
Knowledge / Skill / Abilities
List the abilities you possess and believe relevant to the position you seek, such as computer skills, bilingual, etc.
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Knowledge / Skill / Abilities
How did you hear about us?
How did you hear about us?
Walk–in
News Paper/ Magazine
Friends/Family
Online
Website
Other
How did you hear about us? (other)
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How did you hear about us?
Background Information
ARE YOU LEGALLY AUTHORIZED TO WORK IN THE U.S.?
(Required)
Yes
No
WERE YOU EVER DISCHARGED FROM ANY EMPLOYMENT, REJECTED DURING YOUR PROBATIONARY PERIOD, OR HAVE YOU EVER RESIGNED UNDER THE THREAT OF DISCHARGE FROM ANY EMPLOYMENT?
(Required)
Yes
No
Discharged or rejected during your probationary period: Please explain
(Required)
WERE YOU EVER CONVICTED OF A SEXUAL CRIMINAL OFFENSE AGAINST A MINOR?
(Required)
Yes
No
If, you answered “
YES
” in accordance with
Act #6182
, in order to attain employment, you must register with the Virgin Islands Department of Justice and provide evidence of registration.
HAVE YOU EVER BEEN CHARGED, CONVICTED, PLED NO CONTEST, OR PLED GUILTY TO A CRIME, WHICH IS A FELONY OR A MISDEMEANOR?
(Required)
Yes
No
What charge?
(Required)
Where were you convicted and what Date?
(Required)
HAVE YOU EVER WORKED AT SCHNEIDER REGIONAL MEDICAL CENTER?
(Required)
Yes
No
Position
(Required)
Position End Date
MM slash DD slash YYYY
Position Start Date
MM slash DD slash YYYY
ARE YOU RELATED TO ANYONE WHO WORKS AT SCHNEIDER REGIONAL MEDICAL CENTER?
(Required)
Yes
No
Employee's Name
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Relationship
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Background Information
Veterans Preference Information
DO YOU CLAIM VETERAN’S PREFERENCE, IF ELIGIBLE?
(Required)
Yes
No
Veteran’s preference: Check one
Veteran
Widow or Widower of a Veteran
Spouse of a disabled veteran
DID YOU SERVE IN ACTIVE DUTY FOR THE U.S. MILITARY
(Required)
Yes
No
What was your discharge?
Honorable
Dishonorable
General
Other
What was your discharge? Explain.
(Required)
Do you have a service connected disability (rated 10% or more by V.A)?
(Required)
Yes
No
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Veterans Preference Information
(Optional) EEO Survey
Gender
Male
Female
Ethnicity
African American
Caucasian
Hispanic
Asian
Other
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(Optional) EEO Survey
Disclaimer
I acknowledge that Schneider Regional Medical Center operates twenty-four (24) hours a day and seven (7) days a week. By signing below I understand that work hours may vary based on the position I am applying for. I am also aware that any
omission, falsification, misstatement, or misrepresentation
above may disqualify me for employment consideration and if I am hired, may be grounds for termination at a later date. I understand that any information I give may be investigated as by law. I consent to the release of information about my ability, employment history, and fitness for employment by employers, schools, law enforcement agencies, and other individuals and organizations, investigators, personnel staff, and other authorized employees of the Virgin Islands Government for employment purposes. I understand and accept the fact that my consent shall remain effective during the tenure of my employment should I be hired. I certify to the best of my knowledge and belief all of the statements contained herein and on any attachment are
true, correct, and made in good faith
.
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