If “Yes”, please specify (Hospital policy may affect work assignment of related employees.)

Have you ever been convicted of a crime other than traffic infractions? yes no
If “Yes”, please explain and state charge, court, date and disposition of case
Note: Convictions are not an automatic bar to employment. Each case will be considered on its own merits.

Education
Select highest grade completed:
1   2   3   4   5   6   7   8   9   10
11   12   13   14   15   16   17   18

College or University Location Course Degree

Graduate School Location Course Degree

Other

Are you registered or certified by any professional organization, or do you hold a
professional or occupational license in the State of California? yes no
If Yes, please specify
Registration of License No. Exp. Date Type

Source of Referral: Self Newspaper School EDD Other
Employee Referral? Name:

ADDITIONAL INFORMATION

To the Applicant: The Civil Rights Act of 1964 prohibits discrimination in employment because of race, color, religion, sex or national origin. Federal laws also prohibit other types of discrimination, such as age, citizenship, disability, veteran status, attainment of benefits or participation in union activities. The laws of many states and localities also prohibit some or all of these types of discrimination, as well as prohibiting other types of discrimination, such as discrimination based on ancestry, parental or marital status, sexual orientation, or source of income.

Are you able to perform each of the essential job functions listed for this position with or without accommodation? yes no
If you can perform the job functions with an accommodation, please describe how you would perform the job functions and with what accommodations.

Are you a Vietnam Veteran? yes no
Are you eligible to be bonded? yes no

I understand that the Immigration Reform and Control Act of November 6, 1986 requires me to prove the legality of my residency or citizenship. I am also aware that the failure to provide such proof at the time of request may legally force termination. To the best of my knowledge the information contained in this application is true. I understand that nothing contained in this employment application or in the granting of an interview is intended to create a contract between me and this hospital for either employment or the provision of any benefits; and further understand that if any employment relationship subsequently is established, I will have the right to terminate my employment at any time and EPHC will have a similar right. In addition, I understand that no promise, representation or agreement contrary to the foregoing is binding on the company unless made in writing and signed by me and an authorized representative of the District.

Applicant’s Signature Date

EMPLOYMENT HISTORY

1. Start with most recent employment first.
2. Include military experience.
3. Account for periods of unemployment.
4. Place a check by the employer(s) you do not want us to contact.

1.Company Name Phone
Address Emp. Dates
Position Reason for Leaving Last Wage

2.Company Name Phone
Address Emp. Dates
Position Reason for Leaving Last Wage

2.Company Name Phone
Address Emp. Dates
Position Reason for Leaving Last Wage

Do you have a legal right to be employed in the U.S.? yes no

In addition to the information already provided, list any volunteer activities, training, hobbies, special interests or other experience that you feel qualified you for the position for which you have applied. (Please omit those indicating race, color, religion, sex, national origin, ancestry, age or the existence of disability):
___________________________________________________

Last Name First Middle

List Any other name used in the last 7 years

Date of birth Social Security Number

Drivers License # State Phone # (Day)

Professional License Held State Lic.#

List your current mailing address as well as any other cities or towns you have lived in the past 7 years:
Street or PO# City State Zip
City State Zip Dates to
City State Zip Dates to
City State Zip Dates to
City State Zip Dates to

Your Signature (Type name in box this is your digital signature)
Signature of Applicant

Today’s Date

California residents initial here if you wish a free copy of this report mailed to the address you supplied above

*** APPLICANT – DO NOT WRITE BELOW THIS LINE ***

FAX TO: (888) 999-3839 TO BE FILLED OUT BY COMPANY REQUESTING INFORMATION:

Company Name:________________________________________PO/Location #_____________
_____Please start our standard background check (ignore boxes below)
Or select from the following:

___Criminal History ___Civil History ___Credit Report ___Social Security Verification
___ Driving Report ___Education/Degree Verification ____Reference Check
___ National Wants & Warrants ____Professional License Verfication ___Previous Employer Verification ____O.I.G. name search ___ Urine Based Drug Test ___Saliva Based Drug Test

While the information contained in the reports provided has been obtained from public records data deemed reliable, its accuracy cannot be guaranteed due to potential human error in the actual recording of the record. Since this information is not owned by Pre-employ.com, Inc. and since public records data on any one individual, group of individuals, company, or companies can be contained in more than one repository, Pre-employ, Inc. can only rely on its accuracy from the public records data sources presently available at the time of the search. This information is furnished for your exclusive use and accepted by you without any liability on the part of Pre-employ.com, Inc. its sources, officers, agents or employees. Furthermore you agree to indemnify Pre-employ.com, Inc., its sources, agents, and employees of any liability for the use of this information and shall agree that the right to obtain and the purpose for this information. For your exclusive use, is fully within the appropriate law or laws which apply to the permissible purpose of retrieving background information on an individuals criminal records history, credit history and/or workers compensation claim history.

EQUAL OPPORTUNITY EMPLOYER