Westview Hospital

Application for Employment at Westview Hospital

• Required Fields

Personal Information • First Name:
• Middle Name:
• Last Name:
• Email:
• Home Address: • City:
• State:
• Zip Code:
• Social Security No.:
• Phone:
How were you referred to Westview Hospital?
Name and relationship of relative who is a Westview employee. (if applicable):
Who should be contacted in case of an emergency? (full name and telephone number)
Have you been convicted of any crime? (other than minor traffic offense) YES or NO. If YES, please explain.

Employment Desired Position applying for:

Full Time, Part Time, Temporary:

Full Time Part Time Temporary

Shift Preference:

Days Evenings Nights

Desired pay (per hour or per year):

Are you willing to work overtime?

Yes No

Is there anytime you would not be able to work overtime?
Date you can start?

Are you currently employed?

Yes No

May we contact your current employer? If YES, enter your supervisors name and phone number:

Education (list all applicable) High School: List name, location, major subjects, and whether you graduated.
Business/Technical School: List name, location, major subjects, and whether you graduated or not and with what degree.
College/University: List name, location, major subjects, and whether you graduated or not and with what degree.
Post-graduate: List name, location, major subjects, and whether you graduated or not and with what degree.
Subjects of special study or research, or specialized training:

Are you registered/licensed?

No Yes

If yes, occupation:

Work Experience

If you would prefer to email your resume rather than fill out the following WORK EXPERIENCE section, please email the file in text (.txt) or Word (.doc) format file to hr@westviewhospital.org and note in your message that your are filling out an on-line application.

List your last 4 jobs, starting with your current or most recent job. Provide the following information:

Start and end date of employment
Name, location and phone of employer
Name of your supervisor
Position
Reason for leaving

Employer #1
Current or most recent:
Employer #2:
Employer #3:
Employer #4:

References

List 3 persons, not related to you, who have known you for at least 1 year. Provide the following info:

Name
Address
Phone
Business
Years known

Reference #1:
Reference #2:
Reference #3:

Representation and Authorization

I hereby represent and certify that all statements I have made in the application for employment are true and complete to the best of my belief and knowledge. I understand that if I am employed by Westview, any misrepresentations or omissions of facts with regard to this employment application or interviews may be the cause of my immediate termination, regardless of the date of discovery. I hereby authorize Westview to investigate all statements made by me herein or during interviews, and conduct a background and criminal check. If I have been convicted of certain crimes (as defined by Indiana Code), I understand that I will not be permitted to start work or I will be immediately terminated. If employed by Westview, I understand that I will be employed "at will," which means either Westview or myself may terminate my employment at any time, without previous notice. I agree to submit to a physical examination and a drug and alcohol screen after an offer of employment has been made. In the event the examination discloses physical or mental conditions which prevent me from performing the essential functions of my job, with or without accommodation, I understand that the hospital may withdraw its offer of employment. By sending this form, you are agreeing to the above Terms.