Nebraska Orthopaedic Hospital Application For Employment
 
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Position(s) Applied For:
 Date Available to Start Work:
 Date of Application:
Minimum Salary Requirement:  
  Hourly  Annual		 Work Availability (check all that apply):
Part Time  Full Time  Casual		 Shift Availability (check all that apply):
Day  Evening  Night  Weekend
How did you learn about the position?  
         
Personal Information  
Last Name:
 First Name:
 Middle Name:
Street Address:
 City:
 State:
 Zip:
Home Phone:
 Other Phone:
 e-Mail Address:
Any special training or skills (languages, machine operations, etc.)?
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Have you previously applied for employment with Nebraska Orthopaedic Hospital? Yes  No
If Yes, give date(s) and position(s):
  
Have you ever been employed by Nebraska Orthopaedic Hospital? Yes  No
If Yes, give date(s) and position(s):
  
Do you have any friends or relatives that work for Nebraska Orthopaedic Hospital? Yes  No
If Yes, state name and relationship:
  
Are you currently employed? Yes  No
May we contact your current employer? Yes  No
If No, why?
  
Have you ever been bonded? If Yes, when and where. Yes  No
Will you work overtime if asked? Yes  No
Are you prevented from lawfully becoming employed in the United States because of Visa or Immigration Status?
(Proof of citizenship or immigration status will be required upon employment.)		 Yes  No
Have you ever been arrested or convicted of any crimes, including misdemeanors and/or felonies? Yes  No
If Yes, please explain: (Such arrests or convictions may be relevant if job related, but would not automatically bar you from employment. Each case is considered individually)
  
If you are licensed, registered or otherwise credentialed, have you ever been suspended, placed on probations
or had other disciplinary actions taken against you?		 Yes  No
If Yes, please explain:
  
       
References  
Name: Telephone Number: Years Known: Occupation/Company/Relationship:
 
 
 
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Education       
High School: Number of Years Attended: Did you Graduate?
YesNo
Street Address: City: State: Zip:
Course of Study: List Degrees/Licensure/Certifications:

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Vocational/Technical School: Number of Years Attended: Did you Graduate?
YesNo
Street Address: City: State: Zip:
Course of Study: List Degrees/Licensure/Certifications:

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College: Number of Years Attended: Did you Graduate?
YesNo
Street Address: City: State: Zip:
Course of Study: List Degrees/Licensure/Certifications:

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Other: Number of Years Attended: Did you Graduate?
YesNo
Street Address: City: State: Zip:
Course of Study: List Degrees/Licensure/Certifications:

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Work Experience     Please give an accurate, complete full and part-time employment record. Start with your most recent position.
Company Name (1): Name of Supervisor: Telephone Number:
Street Address: City: State: Zip:
Employed From: Employed To: Pay Start: Pay Finish:
Position Title - Work Performed Reason for leaving:

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Company Name (2): Name of Supervisor: Telephone Number:
Street Address: City: State: Zip:
Employed From: Employed To: Pay Start: Pay Finish:
Position Title - Work Performed Reason for leaving:

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Company Name (3): Name of Supervisor: Telephone Number:
Street Address: City: State: Zip:
Employed From: Employed To: Pay Start: Pay Finish:
Position Title - Work Performed Reason for leaving:

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Company Name (4): Name of Supervisor: Telephone Number:
Street Address: City: State: Zip:
Employed From: Employed To: Pay Start: Pay Finish:
Position Title - Work Performed Reason for leaving:

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Military  
Have you or do you serve in the U.S. Armed Forces?  Yes  No
If "Yes" in what Branch did you serve?
Describe any training you received relevant to the position for which you are applying:

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License/Certifications         
Type: State: Date Issued: Date Expired: Registration Number:
BLS
ACLS
   
Skills/Information:     Describe any additional specialized training or skills you would like us to consider as a part of your application.

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Other Activities: List  professional, trade business or other civic activities and offices held. You may exclude any information that would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status.

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Applicant Information     Please read and understand the statement below before signing you application.

 
   The information I have provided to Nebraska Orthopaedic Hospital, LLC (NOH) in this Application for Employment ("Application") is true, correct and complete. I understand that false, incomplete or misrepresented information of any kind, will be sufficient cause for my Application to be rejected or, if discovered after I am employed, cause for immediate termination of my employment.

   I authorize NOH to contact and obtain information about me from previous employers, educational institutions and references I provided, and any other party necessary to verify the accuracy of information I disclosed in this Application, a related employment resume or a personal interview. To assist in the processing of my Application, I waive all rights and claims I may otherwise have against NOH and all other persons, corporations or organizations who provides information for this purpose. I agree that if I've been convicted of a crime, the authorities of NOH may obtain the details of my conviction to determine its relationship to the position I'm applying for a condition of my employment.

   Any offer of employment I may received is contingent upon my successful completion of the pre-employment screening process, including NOH receiving references that it considers satisfactory and my satisfactory completion of any post-job offer pre-employment physical examination which the employer may require.

   If hired, I agree to comply with NOH's policies, rules, regulations and procedures, and I understand that my employment would be "at will". This means that, just as I am free to resign at any time, NOH reserves the right to terminate my employment at any time for any reason and without prior notice. This Application is not an employment agreement. I understand that no one, other than an executive officer of NOH, has authority to enter into any employment agreement with terms contrary to the foregoing and then only if the agreement is in writing and sighed by such officer.

   I fully understand and accept all terms and conditions in the above statement.

 
Applicant Signature
 Date
 
 
 
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VOLUNTARY SELF-IDENTIFICATION FORM
The following statistical information is used only for compliance with federal laws assuring equal employment opportunity without regard to race, color, sex, national origin, religion, age, disability, veteran status or any other classification protected by federal, state, or local law. Completion of this data is voluntary and will not affect your opportunity for employment or terms or conditions of employment, if hired.
Name: Address:
Position Applied For: Gender:
Male  Female
Referral Source:
Unsolicited Advertisement Employee Referral
Employment Agency College Recruitment Other-Specify: 
Race/Ethnic Identification: (Please check one of the descriptions below corresponding to the ethnic group with which you identify.)
 
Hispanic or Latino: A persons of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race.
If you check the above, which race do you consider yourself Hispanic or Latino?
 
If you did not check "Hispanic or Latino" above, please check one of the following race/ethnic identifications.
 
White (Not Hispanic or Latino): A person having origin in any of the original peoples of Europe, North Africa or the Middle East.
 
Black or African American (Not Hispanic or Latino): A person having origins in any of the black racial groups of Africa.
 
Native Hawaiian or Other pacific Islander (Not Hispanic or Latino): A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
 
Asian (Not Hispanic or Latino): A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
 
American Indian or Alaska Native (Not Hispanic or Latino): A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
 
Two or More Races (Not Hispanic or Latino): All persons who identify with more than one of the above five races.
 
Regulations issued by the U.S. Department of Labor with respect to disabled individuals, disabled veterans, and Vietnam Era veterans require that federal contractors provide an opportunity for self-identification to candidates seeking employment. Such self-identification is submitted on a voluntary basis, on a confidential basis, for use only in accordance with regulations, and without subjecting the individual to adverse treatment.
Disabled/Veteran Status: (Please check one if it describes your veteran status.)
 
Disabled Individual: Federal regulations define a disabled person as one who (1) has a physical or mental impairment which substantially limits one or more of such person's major life activities, (2) has a history of such impairment, or (3) is regarded as having such an impairment.
 
Vietnam Era Veteran: Federal regulation define a veteran of the Vietnam Era as one who (1) served on active duty for a period of more than 180 days, any part of which occurred between August 5, 1964, and May 7, 1975, and was discharged or released with other than a dishonorable discharge, or (2) was discharged or released from active duty for a service connected disability if any part of such active duty was performed between August 5, 1964, and May 7, 1975.
 
Special Disabled Veteran: Federal regulations define a special disabled veteran as one who (1) is entitled to compensation under laws administered by the Veterans' Administration for a disability rated 30% or more, or (2) was discharged or released from active duty because of a service-connected disability.
 
Applicant Signature
 Date
Nebraska Orthopaedic Hospital
An Equal Opportunity Employer
 
 
 
 

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