application for employment - VAIRKKO

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Team Member Application

www.indianahealth.care inHealth

2700 Valparaiso Street. Unit 1711, Valparaiso, Indiana, 46384

219.545.1796 / [email protected]





inHealth

2700 Valparaiso St. Unit 1711 Valparaiso, IN, 46384 219.545.1796 / [email protected]

APPLICATION FOR EMPLOYMENT

MINIMUM QUALIFICATIONS

18 years of age when applying for EMT or Paramedic. 21 years of age when applying for Med-Car Driver and must have or be able to obtain a Public Passengers Chauffeur License. A Valid Driver’s License with minimal violations. Successfully must be able to complete required testing / Lift Test Paramedic sponsorship (if applicable) with Porter Regional Hospital – State of Indiana Certification. Active Indiana EMT or National Registry Certification with the ability to receive reciprocity into the Indiana EMS system.

GENERAL INSTRUCTIONS

Type or print in ink an answer to every question. To be eligible for consideration, applications MUST be complete, accurate and legible. If a question does not apply to you, mark N/A in the space provided. You are responsible to notify inHealth any change of contact information inHealth may verify conviction record, places of employment and other information listed on this application. If you have any questions, you may call 219.545.1796

EMPLOYMENT INFORMATION Position Desired: (Please Circle) EMT-B Med-Car Driver

EMT-Advanced Office



AVAILABILITY





Sunday Monday Tuesday From To

Paramedic Other:___________________

Wednesday

Thursday Friday Saturday































Please Circle: Full-Time APPLICANT INFORMATION



Part-Time













Date: ________________

Last Name:

First Name:

Middle:





Address:











Zip:













































City:

State:

Phone:

Cell:

Email:



Have you submitted an application with inHealth before? YES NO If YES, give the date(s) and position(s): Have you ever been employed with inHealth before? YES NO If YES, give date(s)

FROM



Driver’s License Number:

TO Issuing State:

Is your driver’s license currently valid?

YES

NO Expiration Date:

Have you ever been debarred, suspended, excluded, or otherwise ineligible for participation in federal health care programs? YES NO If YES, please explain:











inHealth

2700 Valparaiso Street. Unit 1711, Valparaiso, Indiana, 46384

219.545.1796 / [email protected]



Have you ever been convicted of a felony? YES NO If YES, please explain: _________________



____________________________________________________________________________________



Have you ever been placed on probation? YES NO If YES, please explain: ____________________



____________________________________________________________________________________



Have you ever used or experimented with any non-prescribed controlled substances or illegal drugs? YES NO

If YES, please explain: _________________________________________________________________

EDUCATIONAL INFORMATION High School:

Degree or Diploma:

Dates Attended: (from/to)

Degree or Diploma:

Dates Attended: (from/to)

Degree or Diploma:

Dates Attended: (from/to)

Degree or Diploma:

Dates Attended: (from/to)

Degree or Diploma:

Dates Attended: (from/to)

College:

Graduate:

Technical EMT & Paramedic:

Other:





List scholastic honors, offices held, and activities in high school or college:

Computer Skills:



EXPERIENCE

(Please state your professional work experience, certifications, or special training.) Experience Certifications and Numbers

Expiration Date





















inHealth

2700 Valparaiso Street. Unit 1711, Valparaiso, Indiana, 46384

219.545.1796 / [email protected]



EMPLOYMENT HISTORY Company: _____________________________

Company: _____________________________

Address: ______________________________

Address: ______________________________

City, State, Zip: ________________________

City, State, Zip: ________________________

Employed From: _________ To: ___________

Employed From: _________ To: ___________

Position Held: __________________________

Position Held: __________________________

Supervisor: ____________________________

Supervisor: ____________________________

Phone: _______________________________

Phone: _______________________________

Rate of Pay: ___________________________

Rate of Pay: ___________________________

Responsibilities: _______________________

Responsibilities: ________________________

______________________________________

______________________________________

______________________________________

______________________________________

Reason for Leaving: _____________________

Reason for Leaving: _____________________

______________________________________

______________________________________

May we contact this employer: YES NO

May we contact this employer: YES NO

If NO, please share why: _________________

If NO, please share why: _________________

______________________________________

______________________________________





Company: _____________________________

Company: _____________________________

Address: ______________________________

Address: ______________________________

City, State, Zip: ________________________

City, State, Zip: ________________________

Employed From: _________ To: ___________



Employed From: _________ To: ___________

Position Held: __________________________

Position Held: __________________________

Supervisor: ____________________________

Supervisor: ____________________________

Phone: _______________________________

Phone: _______________________________

Rate of Pay: ___________________________

Rate of Pay: ___________________________

Responsibilities: _______________________

Responsibilities: _______________________

______________________________________

______________________________________

______________________________________

______________________________________

Reason for Leaving: _____________________

Reason for Leaving: _____________________

______________________________________

______________________________________

May we contact this employer: YES NO

May we contact this employer: YES NO

If NO, please share why: _________________

If NO, please share why: _________________

______________________________________

______________________________________

inHealth

2700 Valparaiso Street. Unit 1711, Valparaiso, Indiana, 46384

219.545.1796 / [email protected]

PROFESSIONAL REFERENCES

List the name and telephone number of three references that are not related to you and not former employers. These references should have knowledge of your capability to perform the duties of the position you are seeking. Name: Phone: Relationship: Years Known:

Name:

Phone:

Relationship:

Years Known:

Name:

Phone:

Relationship:

Years Known:



VOLUNTEER EXPERIENCE/ WORK INTERNSHIPS (FIREFIGHTER/ EMT/ PARAMEDIC/ OTHER MEDICAL SERVICES)

Organization:



























Address:



























Phone Number:









Position Held:













From: sdfg







To:







# Of Hours Worked Weekly





Supervisor:













Title:











Describe Responsibilities:

























































































APPLICANT’S STATEMENT I have read and fully understand the questions asked in this application. I certify that all of the answers I have given are true, accurate and complete. I understand that the omission and/or misrepresentation of any fact from or on this application or during any interview will result in immediate rejection of my application or if I am hired will be cause for immediate dismissal. Unless I noted otherwise, I authorize inHealth to contact all my employment references and other references, as well as the educational institutions I have attended. I further authorize inHealth to inquire about, investigate and obtain copies of any records which relate to me from my former employers and educational institutions. I hereby release inHealth, as well as any person or institution that provides inHealth. with any lawful information about me, from any and all liability whatsoever resulting from any such lawful inquiry, investigation or communication. I understand that any hiring decision is contingent upon my successful completion of all of inHealth’s lawful pre-employment background check and testing. I agree to execute any forms necessary for inHealth to conduct its established practice. It is the policy of inHealth to provide equality of opportunity to all persons regardless of race, color, national origin, sex, age or disability. This policy applies to all aspects of our personnel policies, practice and operations. inHealth complies with the Americans with Disabilities Act (ADA). Persons needing accommodations in the recruitment process should notify inHealth in advance. All information contained in or connected with this application will be considered personal and confidential and used only in conjunction with your possible employment by inHealth. Please furnish us with complete information as outlined in this application. Any misrepresentation on this application whether actual or by omission may disqualify you for consideration of employment by inHealth. and post employment. In consideration of my employment, I agree to conform to the policies and procedures of inHealth

_____________________________________________________________ Applicant Signature









FOR INTERNAL USE ONLY Date Received: Received by: Interviewed by HR: Interviewed by Hiring Manager: Offer Extended: YES NO Date Notified: Position: Rate of Pay: inHealth









2700 Valparaiso Street. Unit 1711, Valparaiso, Indiana, 46384





__________________ Date

Walk-in Mail Fax Email Other Date: Date: Date Accepted: Orientation Date: ___________________ 219.545.1796 / [email protected]

BACKGROUND AUTHORIZATION



I authorize and empower inHealth and it’s representatives, or any other outside service company engaged by said organization for this purpose, now or subsequently, to obtain, prepare, use and furnish information concerning my current and former employment, education, general reputation and other relevant information, through correspondence or personal interviews with neighbors, friends, or others with whom I am acquainted or who have knowledge concerning any of the above items.

I certify that I have read this authorization form and understand its meaning and purpose.

PLEASE PRINT NEATLY AND MAKE SURE THE PRINTING IS LEGIBLE First Name:

Middle Name:

Last Name: Maiden Name: Date Changed: Other Last Names Used: Date Changed: Other Last Names Used: Date Changed: Other Last Names Used: Date Changed: List all cities and states where you have lived for the past 7 years - Attach additional sheet if necessary Street City, State Zip How Long? Current: 2. 3. 4. Present Phone Number (with area code): Social Security Number: Date of Birth* (MM/DD/YYYY): Gender: / / Driver’s License Number: Driver’s License State: *This information will be used for background screening purposes only and will not be used as hiring criteria.

inHealth

2700 Valparaiso Street. Unit 1711, Valparaiso, Indiana, 46384

219.545.1796 / [email protected]

Invitation To Applicants To Self-Identify



Please Note: You are not required to complete any part of this form. The Equal Employment Opportunity Commission (EEOC) requires organizations with 100 or more employees to invite applicants to self-identify gender and race and complete an EEO-1 report each year. Completion of this data is voluntary and will not affect your opportunity for employment, or terms or conditions of employment. This form will be used for EEO-1 reporting purposes only and will be kept separate from all other personnel records only accessed by the Human Resources department.



APPLICANT INFORMATION



Last Name:









First Name:



Date: ________________

Middle:





Sex: M F Position applying for: __________________________________ Disability Related Data Do you have a disability? ____________ If you answered yes, is your disability one of the targeted disabilities listed below? Yes No The Equal Employment Opportunity Commission targets the following disabilities for extra recruitment efforts: Deaf, Blind, Missing Extremities, Partial / Complete Paralysis, Convulsive Disorders, Mentally Retarded, Mental Illness, or Distortion Limb / Spine

Affirmative Action Related Data Please check one of the descriptions below corresponding to the ethnic group with which you identify. ___ Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. ___ White (Not Hispanic or Latino): A person having origins in any of the original peoples of Europe, the Middle East or North Africa. ___ Black or African American (Not Hispanic or Latino): A person having origins in any of the black racial groups of Africa. ___ Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino): A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands. ___ Asian (Not Hispanic or Latino): A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam. ___ American Indian or Alaska Native (Not Hispanic or Latino): A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment. ___ Two or more races (Not Hispanic or Latino): All persons who identify with more than one of the above five races. inHealth

https://www.eeoc.gov/ 2700 Valparaiso Street. Unit 1711, Valparaiso, Indiana, 46384

219.545.1796 / [email protected]

/

inHealth

2700 Valparaiso Street. Unit 1711, Valparaiso, Indiana, 46384

219.545.1796 / [email protected]



inHealth [email protected]

2700 Valparaiso Street. Unit 1711, Valparaiso, Indiana, 46384

219.545.1796 /