Cook/Aide

COMANCHE COUNTY MEDICAL CENTER HEALTH SYSTEM

Equal Employment Opportunity Policy Statement. Comanche County Medical Center Health System is an equal opportunity employer and does not discriminate against applicants or employees because of race, color, religion, national origin, sex, age, disability status of otherwise qualified individuals, military status or any other status protected by law.

Applicant Information

Your Name(Required)

First Middle Initial Last

Date(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

E-mail Address(Required)

Date Available(Required)

Desired Salary(Required)

Position Applying for / Location(Required)

Employment Type(Required)

Full time

Part time

PRN

Select all shifts you are willing and able to work(Required)

Days

Nights

Weekends

Holidays

Other

Other(Required)

Are you at least 18 years of age?(Required)

Yes

No

List any other names you are known by:

Are you a citizen of the United States?(Required)

Yes

No

Are you authorized to work in the U.S.?(Required)

Yes

No

Have you ever worked for this company?(Required)

Yes

No

When did you work for this company before?(Required)

Have you ever been convicted of a felony?(Required)

Yes

No

Please explain(Required)

Have you ever been the subject of any adverse action(s) by any duly authorized sanctioning or disciplinary agency for either conduct based or performance based actions?(Required)

Yes

No

Please explain(Required)

Education

High School(Required)

School Address(Required)

Street Address City State

From(Required)

To(Required)

Did you graduate?(Required)

Yes

No

Degree

College

College Address

Street Address City State

From

To

Did you graduate?

Yes

No

Degree

Other

Other Address

Street Address City State

To

From

Did you graduate?

Yes

No

Degree

Professional License / Certifications / Registries

Certification 1

Type

Issuing Agency

Number

Expiration

Certification 2

Type

Issuing Agency

Number

Expiration

Certification 3

Type

Issuing Agency

Number

Expiration

Certification 4

Type

Issuing Agency

Number

Expiration

Has your license, registry or certification been suspended, limited, revoked or subject to disciplinary action?

Yes

No

Please explain(Required)

References

Please list three professional references. References cannot be relatives.

Reference 1(Required)

Full Name

Relationship

Company

Phone

Address

Reference 2(Required)

Full Name

Relationship

Company

Phone

Address

Reference 3(Required)

Full Name

Relationship

Company

Phone

Address

Previous Employment

Employer 1(Required)

Company

Phone

Address

Supervisor

May we contact your previous supervisor for a reference?

Job 1 Details(Required)

Job Title

Starting Salary

Ending Salary

Responsibilities

From

To

Reason for Leaving

Employer 2(Required)

Company

Phone

Address

Supervisor

May we contact your previous supervisor for a reference?

Job 2 Details(Required)

Job Title

Starting Salary

Ending Salary

Responsibilities

From

To

Reason for Leaving

Employer 3(Required)

Company

Phone

Address

Supervisor

May we contact your previous supervisor for a reference?

Job 3 Details(Required)

Job Title

Starting Salary

Ending Salary

Responsibilities

From

To

Reason for Leaving

Military Service

List

Branch

Rank at Discharge

From

To

Type of Discharge

If other than honorable, please explain

Consent(Required)

I CERTIFY THAT MY ANSWERS ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. IF EMPLOYED, I ACKNOWLEDGE AND UNDERSTAND THAT:

• Any misstatement or omission of fact on this employment inquiry may result in my dismissal.

• If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

• I must submit acceptable evidence of my right to work in the United States.

• CCMC facilities are tobacco, drug and alcohol free workplaces. I must take and pass a pre-employment and drug test that screens for illegal drugs, alcohol, and unauthorized controlled substances; remain free of illegal drugs, alcohol and abusive levels of prescription drugs at work; and comply with the Drug-Free and Tobacco-Free policies.

• I will be required to comply with all Administration policies and procedures.

• I authorize this employment inquiry to be viewed by any affiliated companies.

• I am required to report any known or suspected practices that may violate state or federal law, including, but not limited to Medicare fraud and abuse. I understand that I am required to report such conduct to Human Resources or the CEO.

• I understand that Comanche County Medical Center is an employer at will, which means that my employment is not for a definite term and that either CCMC or I will have the right to terminate the employment relationship at any time, with or without cause or notice. I also understand that this status can only be altered by a written contract of employment that is specific as to all material terms and is signed by the CEO of CCMC and myself.

• Upon termination, I will return in good condition any company property issued to me or to allow for the value of same, plus any outstanding accounts, to be deducted from my wages.

• I agree to notify CCMC in writing within forty-eight (48) hours of receiving any written or oral notice of any adverse action, including, without limitation, exclusion from participation in any federal or state health care or procurement programs, any filed and served malpractice suit or arbitration action; any adverse action by a state licensing board; any adverse action which has resulted in the filing of a report with the state licensing board; any revocation of DEA license; a conviction or charge of any felony, misdemeanor or deferred adjudication; any action against any certification under the Medicare or Medicaid programs; or any cancellation, non-renewal or material reduction in medical liability insurance policy coverage.

• I hereby authorize CCMC to confirm the information that appears in this employment inquiry and authorize all former employers, universities or colleges, references, credit and government agencies, or other persons, firms, corporations and institutions to provide such information to CCMC without delay.

As required by the Fair Credit Reporting Act, notice is given that a consumer report may be made in connection with your employment inquiry. A
consumer report may consist of employment records, educational verification, license verification, driving history, previous addresses or other public
records relative to criminal charges. A credit report will not be requested unless it is deemed pertinent to the functions of the position for which you are
inquiring. If you are denied employment, either wholly or partly, because of the information contained in a consumer report, a disclosure will be made to
you of the name and address of the consumer reporting agency making such a report.

I agree

Signature(Required)

Date(Required)

Phone

This field is for validation purposes and should be left unchanged.

Position Type

Job Location

COMANCHE COUNTY MEDICAL CENTER HEALTH SYSTEM

Applicant Information

Education

Professional License / Certifications / Registries

References

Previous Employment

Military Service

Clinic Locations

Pharmacy Locations

Contact

Employee Links