PRE-ADMISSION FORM (Hospital Patients Only)

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Employment Application

* Required

PERSONAL DATA
non procurement program?

List relatives working for Wayne HealthCare

Name Relationship Department
EDUCATION
SCHOOL SCHOOL, ADDRESS, AND PHONE ATTENDED
Mo Yr.
DID YOU GRADUATE DEGREE AND MAJOR
HIGH
SCHOOL
From
To
Yes
No
COLLEGE
From
To
Yes
No
GRADUATE
STUDY
From
To
Yes
No
Other Training
or Skills
From
To
Yes
No
WORK EXPERIENCE
DATES
Mo. Yr.
COMPANY, ADDRESS, AND PHONE A. Your Position
B. Supervisor
REASON FOR LEAVING
From
To
A.
B.
From
To
A.
B.
From
To
A.
B.
From
To
A.
B.
TO BE COMPLETED BY APPLICANTS FOR CLERICAL POSITIONS
(.pdf or .doc file format only)

If Wayne HealthCare learns during the review of an applicant's qualifications that the applicant otherwise failed to follow ethical or compliance standards of prior employer, Wayne HealthCare may refuse to hire applicant as an employee.

Wayne HealthCare does not retain or hire individuals on the cumulative sanctions list of persons excluded from participation in federal health care programs as prepared by the Office of the Inspector General of the U.S. Department of Health and Human Services. Wayne HealthCare queries the cumulative sanctions report at www.os.dhhs.gov/progorg/org prior to an individual's employment and on a periodic basis for all employees.

Wayne HealthCare does not retain or hire individuals on the List of Parties Excluded From Federal Procurement and Non Procurement Programs. Wayne HealthCare queries the exclusion list at www.amet.gov/epls prior to an individual's employment and on a periodic basis for all employees.

Wayne HealthCare may employ an applicant conditionally prior to obtaining the results of any of the records checks listed above, Wayne HealthCare terminates such conditional employment upon receiving results of check which shows that the applicant is currently excluded from participation in any federal health care program or participation on federal procurement and non-procurement programs.

The facts set forth above in my application for employment are true and correct. I authorize the investigation of all information contained in this form to determine my suitability for employment at Wayne HealthCare. I understand that misrepresentation or omission of facts called for may be cause for dismissal. I also understand that regular employment depends on satisfactory replies from my references, background investigation and successful completion of the probationary period.

  * Signature of Applicant (by checking this box I agree to the above statements)

This application will be kept on file for a period of one(1)year