APPLICATION FOR EMPLOYMENT

Aurora Behavioral Health Care – Vista del Mar is an equal opportunity employer. The Company does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, or any other characteristic protected by applicable state or federal civil rights laws

Date Application Completed: +

Date Available to Begin Work: +

Position Applied For:

Shift:

FT/PT/PD

Salary Desired:

Per Hour/Year

Position Applied For:

Shift:

FT/PT/PD

Salary Desired:

Per Hour/Year

Position Applied For:

Shift:

FT/PT/PD

Salary Desired:

Per Hour/Year

Have you ever worked for Aurora Behavioral Health Care?

Yes

No

If YES, please identify where and when you worked:

Where?

From: +

To: +

Have you previously applied at any Aurora Behavioral Health Care facility?

Yes

No

If YES, when? +

Under what name(s)?

At which facility?

List relatives, friends or roommates currently employed at this Hospital:

PERSONAL INFORMATION

Last Name: *

First Name: *

Middle Name:

Street Address:

City:

State:

ZIP:

Home Telephone:

Message/Cell Telephone:

Email Address

Are you related to, living with or an in intimate relationship with an employee currently working at this facility?

Yes

No

If so, (name):

Are you able to perform the Essential Functions of the position(s) you are applying for, either with or without reasonable accommodations?

Yes

No

Do you have the legal right to work and be employed in the United States? (Proof of identity and legal authority to work in the U.S. is a condition of employment)

Yes

No

Are you at least 18 years of age? (Proof of age and work permits may be required prior to hiring)

Yes

No

Do you have a reliable means of transportation to and from work?

Yes

No

REFERRAL SOURCE

Advertisement (Name of Publication):

Current Employee (Name of Employee):

Other (Job Fair, Walk-in, etc.):

EDUCATION

	Name	Graduated?	# Years Attended	Coursework/Major	G.P.A.
High School	Name	Graduated?	# Years Attended	Coursework/Major	G.P.A.
Community College	Name	Graduated?	# Years Attended	Coursework/Major	G.P.A.
Trade/Vocational School	Name	Graduated?	# Years Attended	Coursework/Major	G.P.A.
College/University	Name	Graduated?	# Years Attended	Coursework/Major	G.P.A.
Other	Name	Graduated?	# Years Attended	Coursework/Major	G.P.A.

EMPLOYMENT/MILITARY SERVICE/VOLUNTEER AND WORK EXPERIENCE

Please identify all positions held in the past ten (10) years and all experience related to the position(s) you are applying for. Include periods of unemployment, self-employment, volunteer activities, school and/or military service.

May we contact your present employer?

Yes

No

May we contact your previous employers?

Yes

No

1. CURRENT OR MOST RECENT EXPERIENCE:

Name of Business:

Type of Business:

Complete Address of Business:

Supervisor's Telephone Number:

Supervisor's Name and Title:

Dates of Service (From): +

Dates of Service (To): +

Position Title/Role:

Duties and Responsibilities:

What did you like most about this role?

What did you like least about this role?

Reason for leaving (resigned, terminated, laid off, relocated, etc.):

2. NEXT MOST RECENT EXPERIENCE:

Name of Business:

Type of Business:

Complete Address of Business:

Supervisor's Telephone Number:

Supervisor's Name and Title:

Dates of Service (From): +

Dates of Service (To): +

Position Title/Role:

Duties and Responsibilities:

What did you like most about this role?

What did you like least about this role?

Reason for leaving (resigned, terminated, laid off, relocated, etc.):

3. NEXT MOST RECENT EXPERIENCE:

Name of Business:

Type of Business:

Complete Address of Business:

Supervisor's Telephone Number:

Supervisor's Name and Title:

Dates of Service (From): +

Dates of Service (To): +

Position Title/Role:

Duties and Responsibilities:

What did you like most about this role?

What did you like least about this role?

Reason for leaving (resigned, terminated, laid off, relocated, etc.):

4. NEXT MOST RECENT EXPERIENCE:

Please describe any additional experience related to the position(s) you are applying for:

PROFESSIONAL LICENSE/CERTIFICATION/REGISTRATION

	Type	Name on License/Certification/Registration	State Issued	Number	Expiration Date (xx/xx/xx)
1	Type	Name on License/Certification/Registration	State Issued	Number	Expiration Date (xx/xx/xx)
2	Type	Name on License/Certification/Registration	State Issued	Number	Expiration Date (xx/xx/xx)
3	Type	Name on License/Certification/Registration	State Issued	Number	Expiration Date (xx/xx/xx)
4	Type	Name on License/Certification/Registration	State Issued	Number	Expiration Date (xx/xx/xx)
5	Type	Name on License/Certification/Registration	State Issued	Number	Expiration Date (xx/xx/xx)

CONDITIONAL OFFER OF EMPLOYMENT

Compliance with the hospital’s Drug-Free Workplace policy is a condition of employment and requires every employee to be free from alcohol and drug abuse. Each offer of employment is contingent upon successfully completing a urinalysis test for alcohol and drugs in accordance with hospital policy. This hospital will not hire any applicant who fails to pass the pre-employment alcohol and drug test. Continued employment is also contingent upon compliance with the hospital’s Drug-Free Workplace policy.

I have read, understand and agree to abide by these conditions of employment: *

Yes

No

I hereby certify that the information contained in this Application for Employment is true and correct to the best of my knowledge and agree to have any of the statements checked by the Company unless I have indicated to the contrary. I authorize the references listed above, as well as all other individuals with whom the Company contacts, to provide the Company any and all information concerning my previous employment and any other pertinent information that they may have. Further, I release all parties and persons from any and all liability for any damages that may result from furnishing such information to the Company as well as from any use or disclosure of such information by the Company or any of its agents, employees, or representatives. I understand that any misrepresentation, falsification, or material omission of information on this Application for Employment may result in my failure to receive an offer or, if I have already been hired, my immediate dismissal from employment.

In consideration of my employment, I agree to conform to the rules and standards of the Company. I further agree that my employment and compensation can be terminated at will, with or without cause, and with or without notice, at any time, either at my option or at the option of the Company. I understand that no employee or representative of the company, other than it’s President, has the authority to enter into any agreement for employment for any specific period of time, or to make any express or implied agreement contrary to the foregoing. Further the President of the Company may not alter the at-will nature of the employment relationship or enter into any employment agreement for a specific period of time unless the President and I both sign a written agreement that clearly and expressly specifies the intent to do so. I agree that this shall constitute a final and fully binding integrated agreement with respect to the at-will nature of employment relationship and that there are no oral, written, or collateral agreements regarding this issue.

I also understand that all offers of employment are condition on the Company’s receipt of satisfactory responses to the reference requests, verification of previous employment, the provision of satisfactory proof of an applicant’s identity and legal authority to work in the United States and other items conducted during a background check. Offers of employment are also condition on the satisfactory completion of a post-offer medical examination.