SHW | Employment Application

700 Constitution Avenue N.E. Washington, D.C. 20002 Human Resources Department: (202) 546-5700 Ext. 2515

Employment Application

Applicants are considered for all positions and employees are treated during employment without regard to race, color, religion, sex, national origin, age, marital or veteran status, sexual orientation, medical condition or disability, ancestry, creed, marital status, personal appearance, family responsibilities, matriculation or political affiliation. As an employer, we comply with government employment regulations. The Specialty Hospital of Washington, also provides "reasonable accommodation" to qualified individuals with disabilities, in accordance with the Americans with Disabilities Act and applicable state and local laws.

Personal Information

Last Name

First Name

Middle Name

Street Address

City State Zip

Home Phone

Work Phone

Contact name and number in case of emergency:

Emergency Name

Emergency Number

If employed and you are under 18, can you furnish a work permit? Yes No

Shift Preference Full Time Part Time PRN

Availability Day Evening Nights Weekends

How did you hear about the position?

Position applied for:

Applying to:

The Specialty Hospital of Washington - Capitol Hill
Capitol Hill Nursing Center
The Specialty Hospital of Washington - Hadley
Hadley Nursing Center

Have you ever been employed by either of the above organizations? Yes No

If yes, when?

Are you legally eligible for employment in the U.S.? Yes No

( Proof of citizenship or immigration status may be required upon employment. )

Have you ever served in the U.S. Armed Forces? Yes No

On what date would you be available for work?

Have you been convicted of a felony within the last seven (7) years? Yes No

(Conviction will not necessarily disqualify an applicant from employment. In making our decision, we will consider many factors such as the age and time of the offense involved, the seriousness and nature of the violation, and whether you have been rehabilitated. We will also consider the nature of the job for which you are applying.)

Please provide a complete list of all employment starting with your most recent employment.

1.) Employer

Employer Name
Street	City
State	Zip
Job Title
Work Performed
Are you employed now? Yes No If yes may we contact your employer? Yes No
Supervisor Name	Supervisor Phone#
Date started	Date ended
Starting Salary	Ending Salary
Reason for leaving

2.) Employer

Employer Name
Street	City
State	Zip
Job Title
Work Performed
Are you employed now? Yes No If yes may we contact your employer? Yes No
Supervisor Name	Supervisor Phone#
Date started	Date ended
Starting Salary	Ending Salary
Reason for leaving

3.) Employer

Employer Name
Street	City
State	Zip
Job Title
Work Performed
Are you employed now? Yes No If yes may we contact your employer? Yes No
Supervisor Name	Supervisor Phone#
Date started	Date ended
Starting Salary	Ending Salary
Reason for leaving

Work Experience: Total Number of Years

Job Related:

Management

Education:

Please list all education and degrees earned:

Degree 1 Date School/College/University

Degree 2 Date School/College/University

Degree 3 Date School/College/University

Degree 4 Date School/College/University

Degree 5 Date School/College/University

Additional Degrees

Skills

Professional Licenses/Certification

License 1

# Exp. Date State

License 2

# Exp. Date State

License 3

# Exp. Date State

Other

Are you certified in CPR Yes No

Date Original Licensure:

Exp. Date:

Is there anything that would prevent you from performing in a reasonable and safe manner the activities involved in the position for which you have applied? Yes No

If yes explain:

I certify that the statements I have made in this application are true and I hereby grant The Specialty Hospital of Washington permission to verify the accuracy and completeness of this information and investigate all references, educational records and criminal background investigation. I understand that any false statements or misleading statements made by me on this application or in connection with my physical examination will be sufficient cause for the rejection of this application or in immediate dismissal if such false or misleading information is discovered after my employment. If accepted for employment, I agree to abide by policies and procedures of the organization.

I understand that if an offer of employment is made, my employment is contingent upon the following:

1.) I must satisfactorily pass the required physical examination
2.) I must satisfactorily complete the required probationary period

I understand that nothing contained in this employment application is intended to create an employment contract between The Specialty Hospital of Washington and myself for either employment or for my benefit. No promises regarding employment have been made to me. If an employment relationship is established, I understand that my employment will be at-will and I or The Specialty Hospital of Washington will have the right to terminate my employment at any time for any reason.

I have read and understand the above information Date