NP / PA - Urology Perrysburg

First name*

Last name*

Email address*

Location *

Phone number*

Resume

Cover Letter

What’s your highest level of education completed?*

References: Please enter names and contact information:*

List all schools you have attended or are currently attending. Include Name and Location of School or College, Course or Major, Number of Years Attended, If you Graduated and Degree Obtained(if applicable).*

List all former employers. For each employer include Name of Employer, Position Held, Dates of Employment, Starting Salary, Last Salary and Reason for Leaving.*

How did you hear about this position?*

Are you 18 years of age or older?*

Are you legally authorized to work in the United States?*

Do you have reliable transportation?*

Do you have a Professional Certification or Registration Number? (RN, LPN, LAB or Other)*

License, certification or registration number:

Have you ever been convicted of a felony?
(Conviction of a crime will be considered only as it relates to the job in question and will not necessarily disqualify an applicant.)*

Were you previously employed by Wood County Hospital?*

Name used while employed at Wood County Hospital:

Shift Desired:*

What do you want to work?*

How much notice will you require when accepting a new position*

Disclosure Information:
Information Certification-
The facts set forth in my application for employment are true and complete. I understand that if employed, false statements and/or omission of pertinent data on this application shall be considered sufficient cause for dismissal.

Records and References-
In connection with my application for employment (including contract for services) with you, I understand that investigative background inquiries are to be made concerning myself including consumer reports, criminal, driving and other reports. These reports may include information as to my character, credit worthiness, general reputation, personal characteristics, mode of living, work habits, performance, and experience along with reasons for termination of past employment from previous employers. I have the right to request disclosure of the nature and scope of the report, which involves personal interviews with sources such as neighbors, friends or associates.
As an applicant for a position with Wood County Hospital and its subsidiaries, I authorize the release of any and all information the references on this application may have concerning me, including information of a confidential or privileged nature.
I hereby release Wood County Hospital and its subsidiaries, the references on this application, and any others from any liability or damage that may result from giving or receiving the information requested.

**Continued Below***

Participation in Wood County Hospital and its subsidiaries' Drug-Free Workplace Initiative-
I hereby certify that I do not use illegal drugs. Furthermore, I agree that, if employed, I will not work under the influence of alcohol or any illegal drug while on duty, or while operating a vehicle or equipment owned or leased by the hospital.

I authorize, without reservation, any party or agency contacted by this employer or its agent to furnish the above mentioned information.

If you agree to all of the above statements, please type your full legal name below.
(First, Middle, Last)*

Human Check*