Apply For A Job

Applicant Questionnaire

Name and Position Applying For

Name	Last, First, M.I.
Date
Position Applied For

Instructions

The Regional Cancer Center/RCC is required to comply with government record keeping and reporting requirements. As a result, we are asking for you to complete the information below. Please check one box that applies to you in each category. This information is voluntary and will not be used in the employment decision-making process. This information will be separated from your application for employment and be kept in a separate, confidential file.

Applicant Information

Gender	Male Female
Race	White Black/African American Hispanic Asian or Pacific Islander America Indian or Alaskan Native RCC uses Government race/ethnicity classifications

RCC is an equal opportunity employer. Policy prohibits discrimination in hiring or employment on the basis of race, color, religion, national origin, ancestry, sex, age, martial status, familial status, sexual orientation, disability, or status as a covered veteran. Further, RCC will continue to support and promote equal employment opportunity, human dignity, and racial, ethnic, and cultural diversity. This is a commitment made by RCC in accordance with federal, state, and/or local laws and regulations.

Employment Application

Personal Information

Legal Name	Last, First, Middle
Address
City
State
Zip Code
Phone Number
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?	Yes No (Proof of citizenship or immigration status may be required upon employment.)
If your former employment, references, education or military service may be under a name other than indicated above, please indicate.	Last, First, Middle

Education

Names and complete address of schools or institutions and degrees	professional training or degrees, if applicable
Names and complete address of schools or institutions and degrees	professional training or degrees, if applicable
Names and complete address of schools or institutions and degrees	professional training or degrees, if applicable

Position Applied For

1st Choice
2nd Choice
Status	Full Time Part Time Temporary Per Diem Please check all that apply
Date Available
State any hours and/or days you are not available to work:	(Other than for religious observance)
Would you have adequate means to get to and from your work at this organization?	Yes No
Are you related or married to a RCC employee?	Yes No This organization does not hire first line blood relatives or spouses to work in the same section or work unit or to work in a section supervised by such a relative. Please state whether this disqualifies you to work in any department in this organization.
If yes, which department(s) and shift(s)
Have vou ever worked for this organization?	Yes No
If yes, give dates of employment and position
Clerical	Typing Shorthand Medical Trans Medical Terminology Dictaphone Data Entry Keying Word Processing Please check all that apply
Clerical Notes	please list wpm for typing, shorthand, and medical trans.
Mechanical	Equipment Repair Plumbing Carpentry Air Conditioning Pipe Fitting Electricity Electronics Refrigeration Please check all that apply

Work History

Give a complete record of all employment. Including U.S. Military Service.

May we contact your present employer for a reference?	Yes No

Last or Present Employer
Address	Address, City, State, Zip
Telephone #
Immediate Supervisor
Dates Employed	From-To
Job Title
Descriptions of Work
Reason for Leaving

Last or Present Employer
Address	Address, City, State, Zip
Telephone #
Immediate Supervisor
Dates Employed	From-To
Job Title
Descriptions of Work
Reason for Leaving

References

Please do not list relatives, previous employers, or persons you have known less than one year

Name
Address	Address, City, State, Zip
Telephone #

Name
Address	Address, City, State, Zip
Telephone #

Name
Address	Address, City, State, Zip
Telephone #

Have you ever pleaded guilty to, or been convicted of a felony within the last seven years?	Yes No A felony conviction will not necessarily be a barrier to employment. We will consider the nature of the crime, subsequent rehabilitation and any other factors in evaluating whether hiring you would promote a security or other risk.

EMPLOYMENT IS DEPENDENT UPON SATISFACTORILY PASSING AN EMPLOYMENT PHYSICAL GIVEN TO ALL PROSPECTIVE EMPLOYEES.

I hereby certify that the foregoing statements are true and correct to the best of my knowledge and belief and hereby grant Regional Cancer Center (RCC) permission to verify such answers and investigate work and personal references. I understand that any false statements on this application or in any interview may be considered sufficient cause for rejection of this application or for dismissal if such false information is discovered subsequent to my employment. I understand that no representation made by RCC or its supervisors, whether in writing or made orally, constitutes a contract of employment or implies any promise or limitation regarding specific policies or benefits, etc. or limits RCC right to discharge me without notice or liability to me for salary or wages, except such as may have been earned up to the date of termination of service. I also understand that my salary, wages, benefits and other terms or conditions of employment are subject to change by RCC and, if hired, I will be notified of these changes. I hereby agree to take a physical and other examinations whenever required by RCC. I also understand that RCC is considering establishing a smoke·free environment in many areas of the organization and thereby may be banning the use of all smoking materials in these areas by employees while on the premises. I authorize the employers, schools or persons named above to give any information regarding my previous employment, character, general reputation and personal characteristics, together with any information that they have regarding me whether or not it is in their records. I understand that under the Federal Fair Credit Reporting Act, I have the right to make a written request within a reasonable period of time for a complete and accurate disclosure by RCC of the nature and scope of any investigation requested by RCC of a consumer reporting agency. If this application for employment is denied either wholly or partly because of information contained in a consumer report from a consumer reporting agency, the applicant understands that RCC shall so advise him or her and shall supply the name and address of the consumer reporting agency making the report. I hereby release said agency, employers, schools or persons from all liability for any damage issuing this information. In addition, if accepted for employment, I hereby agree to abide by the rules and regulations of RCC and to accept the established pay period of RCC.

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