Schuyler Ridge - Job Application

Job Application

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*First Name

*Last Name

*Address

Address 2

*City

*State

*Zip

*Home Phone

E-mail

*Position Applied For

*Date you can start:

Other positions/locations you would consider:

The position I am applying for is at:

Schuyler Ridge
St. Mary's Hospital

*Desired Status:

Full time
Part time
Per Diem
Temporary
Other:

*Preferred Shift:

Days
Evenings
Nights
Weekends

*Referred By:

Seton employee
Job fair
Radio
Newspaper Ad
Other:

Have you ever worked for Seton Health at any of its locations?

No Selection
No
Yes

(If YES, please give dates/position)

Do you have relatives employed at Seton Health?

No Selection
No
Yes

(If YES, please give relative's name/position)

Have you ever been convicted of a crime?

No Selection
No
Yes

(If YES, please explain)

Do you currently have an arrest or criminal proceeding pending which has not been resolved in your favor? Are you under investigation or have you ever been sanctioned under the Medicare or Medicaid program?

No Selection
No
Yes

(If YES, please explain)

Occupation:

Credential Type

License
Registration
Certification

State Issued In:

Number:

Expiration Date:

Have your license(s)/registration(s)/certification(s) ever been subject to disciplinary action - such as suspension or revocation - OR, are you currently under investigation which may result in disciplinary action with respect to your license(s)?

No Selection
No
Yes

(If YES, please explain)

High School

Name / Address
Years Completed
Course Of Study
Degree Received

College / University

Name / Address
Years Completed
Course Of Study
Degree Received

Graduate School

Name / Address
Years Completed
Course Of Study
Degree Received

Military / Technical Training

Name / Address
Years Completed
Course Of Study
Degree Received

Work History 1:

Company Name / Address
Supervisor Name / Phone
Start Date
End Date
Position / Duties
May we contact Supervisor?	Yes No
Reason for leaving
Last Salary

Work History 2:

Company Name / Address
Supervisor Name / Phone
Start Date
End Date
Position / Duties
May we contact Supervisor?	Yes No
Reason for leaving
Last Salary

Work History 3:

Company Name / Address
Supervisor Name / Phone
Start Date
End Date
Position / Duties
May we contact Supervisor?	Yes No
Reason for leaving
Last Salary

Work History 4:

Company Name / Address
Supervisor Name / Phone
Start Date
End Date
Position / Duties
May we contact Supervisor?	Yes No
Reason for leaving
Last Salary

Reference 1:

Name
Phone Number
Relationship

Reference 2:

Name
Phone Number
Relationship

Reference 3:

Name
Phone Number
Relationship

Attestation:

By clicking submit I am hereby attesting the above information is accurate and complete. I understand that omission, misrepresentation or falsification of information is grounds for withdrawal of any job offer and or immediate discharge.

Schuyler Ridge Human Resources
1 Abele Boulevard
Clifton Park, NY 12065

(518) 371-1400 Main Line
(518) 373-3178 Job Hotline

jobs@schuylerridge.org Email