Evansville Surgery Center

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The Evansville Surgery Center is dedicated to compliance with the Civil Rights Act of 1964 and 1991, the Age Discrimination in Employment Act of 1967, the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990, and all federal, state and local laws that govern employment. Please inform the Human Resources Department if you need assistance during the application process.

Please provide all information requested to assure that all your qualifications are fairly considered for current or future vacancies. This application may not be considered unless completed in full. Your application will remain in our active files for 1 year, after which re-application is necessary. The submission of this application does not automatically result in an employment interview or a job offer.

First Name: *
Middle Name:
Last Name: *
Address: *
City: *
State: *
Zip Code: *
Phone Number: *
Email Address: *
Social Security Number: *

Position Applied For:
Type of Employment Desired:	Full Time Part Time Casual
Shift Preference:
Minimum Salary Requirement: *
What Prompted Your Application?:	Newspaper Ad Web Site Employee Referral Other

Type of School:
Name of School:
Major:
Did you graduate?	Yes No
Diploma/Certificate:

Type of School:
Name of School:
Major:
Did you graduate?	Yes No
Diploma/Certificate:

Type of School:
Name of School:
Major:
Did you graduate?	Yes No
Diploma/Certificate:

Type of School:
Name of School:
Major:
Did you graduate?	Yes No
Diploma/Certificate:

(Select any that apply and rate your expertise)
10 Key Calculator:
Accounting:
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Insurance, ICD-9/CPT Coding:
Medical Records:
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Special skills, training and/or expertise (include any accomplishments, achievements and/or special contributions:

(Please list any professional registration, license and/or certification information.)

Type:
Number:
Date of Issue:
Expiration Date:
State:

Type:
Number:
Date of Issue:
Expiration Date:
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Type:
Number:
Date of Issue:
Expiration Date:
State:

Please list any professional/technical memberships you have that are job related:

In the following fields, give a complete record of your employment, starting with your most present or most recent employer.

Present or Last Employer:
Address:
City:
State:
Zip:
Phone:
Name While Employed:
Job Title:
Start Date:
End Date:
Starting Salary:
Ending Salary:
Supervisor's Name:
Summary of Duties:
Reason for Leaving:

Employer:
Address:
City:
State:
Zip:
Phone:
Name While Employed:
Job Title:
Start Date:
End Date:
Starting Salary:
Ending Salary:
Supervisor's Name:
Summary of Duties:
Reason for Leaving:

Employer:
Address:
City:
State:
Zip:
Phone:
Name While Employed:
Job Title:
Start Date:
End Date:
Starting Salary:
Ending Salary:
Supervisor's Name:
Summary of Duties:
Reason for Leaving:

Please list three personal/character references. A personal reference should be an individual who has known you for at least one year and is not a relative.

Name: *
Address: *
Daytime Phone: *
Years Known: *

Name: *
Address: *
Daytime Phone: *
Years Known: *

Name: *
Address: *
Daytime Phone: *
Years Known: *

Have you ever been convicted of a crime, excluding minor traffic violations?
* Yes No

If yes, please list the citation, date, court and place where the offense occured. Please Note: a citation does not necessarily disqualify you from consideration for employment. Please explain so that an informed decision can be made.

I voluntarily authorize the Evansville Surgery Center to make a thorough pre-employment investigation, including a limited criminal history background check. I understand that I have the right to obtain a copy of that report at my own expense and to challenge any information in it that I believe to be inaccurate. I hereby authorize former and present employers and others to provide or verify any information they have regarding my employment or me and release them from any liability for furnishing such information to the Evansville Surgery Center. I understand that employment is contingent on satisfactory outcomes of reference and background checks. All information in this application and employment-related documents is true and complete. I understand that if I am employed, false statements on this application and employment-related documents shall be considered sufficient cause for dismissal. If I receive an offer for employment, I agree to have a medical evaluation and understand that my employment is contingent on passing the evaluation. I agree to take such future medical evaluations as may be lawfully required by the Evansville Surgery Center. I understand that I may be required to work weekends and overtime, and hereby agree to do so. I agree to accept a temporary shift or unit change whenever emergency conditions warrant. I further understand that my employment and compensation can be terminated with or without cause and with or without notice at any time at the option of an authorized Evansville Surgery Center representative or me. If employed, I agree to abide by the policies, procedure and rules of the Evansville Surgery Center and the department to which I am assigned. I further agree to protect the confidentiality and privacy of any information regarding the Evansville Surgery Center and its patients.

* I accept I do not accept

* Date:

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