Career Application

Your Name
Your Address
Position Desired 
Are you authorized to work in the United States? 
Hours Desired
Do you have a professional license related to this job?

Please give accurate, complete full-time and part-time employment record. Start with your present or most recent employer.

Company Address

Please include 3 professional references.

Have you ever been excluded or precluded from participation in Medicare, Medicaid, or any other Federal or State healthcare program or otherwise been disbarred or prohibited from contracting with the Federal or State Government? 
If you have a record of founded child or dependent adult abuse, or have ever been convicted of any misdemeanors or felonies, please explain the record below. 

I hereby certify that all the information provided by me on my Employment Application and in support of my Employment Application is true and complete to the best of my knowledge. I also understand that any misrepresentation or omission of facts on the Employment application is reason for not hiring me or cause for my dismissal, if I am hired. I hereby authorize Orange City Area Health System, in connection with my employment, to contact my schools, employers, or other references unless otherwise stated, and as a result of this investigation, I agree to hold blameless and free of all liability, Orange City Area Health System and all other persons, firms, corporations, schools, hospitals, former employers, and government agencies that provide information from their knowledge or records in direct response to inquiries made by Orange City Area Health System. I realize that the organization will check the Medicare Exclusion List and will request a criminal, child and dependent adult abuse record check on me. Furthermore, if hired by Orange City Area Health System, I understand and agree that: 1. My employment is for no definite period and may be terminated at any time without prior notice. 2. I will comply with all company rules, regulations and policies, written or oral. 3. I will submit to a pre-employment health assessment and follow all health-related requirements. 4. All records pertaining to my employment are and will remain property of Orange City Area Health System.

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