Care New England Online Job Application

We are proud to provide Equal Employment Opportunities to all qualified applicants and employees irrespective of race, color, national origin, sex, gender identity or expression, religion, age, disability or veteran status.

All information must be completed even if resume is attached.

Date: May 17 2012

Name
	Last	First	Middle

Address				-
	Street	City	State	Zip

Home Tel. No.

()

Email Address

Daytime Tel. No.

()

Have you ever worked under a different name? Yes No (If yes, list name)

Primary Position Applied For:

Organization:

Dept./Unit Preference:

Min. Salary Requirement

Per HourWeekYear

Secondary Position Applied For:

Organization:

Dept./Unit Preference:

Min. Salary Requirement

Per HourWeekYear

Other Non-listed Position:

Dept./Unit Preference:

Min. Salary Requirement

Per HourWeekYear

Butler Hospital CNE CNE Home Health Kent Hospital Women & Infants Hospital CNE Wellness Center

If experienced, please mark appropriate boxes
Typing Speed	WPM
Transcription	Yes No
Shorthand/Speedwriting	Yes No
Medical Terminology	Yes No
Computer Software Experience (explain) Access PowerPoint Excel Word Other (explain):

Available for (Check any or all)
	Full Time	Days	Weekends
	Part Time Min Hrs.	Evenings	Summer/Seasonal
	Per Diem (on call)	Nights	Temporary

EDUCATION AND TRAINING

Schools

Name and Address

No.
Years

Pres.
Grade

Grad—
uated?

Type of
Degree

Major
Courses

High/Prep School
or
GED

College/
University/
Nsg. School

Graduate
Study

Business
or
Vocational

Other formal training (include Military Service - experience)

List Professional associations of which you are a member. (State & National Societies,
Professional Clubs, Etc.)

Describe any other skills, experience, or qualifications you have.

This Organization is Subject To The Provisions of The Workers Compensation Act

Professional & Occupational Licensure

Are you now licensed or registered in your profession or occupation?Yes No

In Rhode Island?Yes No

R.I. Licensure or Reg. #

Expiration Date

State and Date where original license or registration was issued

If not licensed or registered in Rhode Island, have you made application?
Yes No

Explain:

Has your license to practice your profession ever been suspended or revoked?
Yes No

Explain:

List any certification:

• Have you ever worked/volunteered at any CNE Organization? Yes No
If so, list: Dates

• Have you ever been sentenced or convicted for any violation of the law? Yes No
If yes, when and for what charge?
A "yes" will not be an absolute bar to employment.

• Have you ever been or are you now barred from participation in any government health care programs including
Medicare, Medicaid, or Champus? Yes No
If yes, explain:

• Referral Source: Ad Walk-In Person Agency Care New England/Hospital Website Other Website/Other Source
Please Specify:

WORK EXPERIENCE


Please complete this section even if submitting resume. List most recent employment first


Name and Address of Employer	Employment Dates		Positions Held	Description of Duties	Reason for Leaving

	Start Date	End Date Current

	Salary:

Supervisor:	Tel. No. () - ext.

May we contact this employer? Yes No If not, why?


	Start Date	End Date Current

	Salary:

Supervisor:	Tel. No. () - ext.

May we contact this employer? Yes No If not, why?


	Start Date	End Date Current

	Salary:

Supervisor:	Tel. No. () - ext.

May we contact this employer? Yes No If not, why?


	Start Date	End Date Current

	Salary:

Supervisor:	Tel. No. () - ext.

May we contact this employer? Yes No If not, why?

LIST OTHER PROFESSIONAL REFERENCES

	Name	Relationship/ Occupation	Address	Tel. No.	Years Known

1.				() - ext.

2.				() - ext.

I hereby certify that the answers given by me to the foregoing questions and the statements made by me are full and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentations of facts called for in this application or any supplements thereto, is cause for rejection of my application or discharge at any time during my employment. I understand that as a condition of employment I will be required to complete the organization's pre-employment physical examination and background checks. I understand that any offer of employment is contingent on my producing appropriate documentation verifying my identity and employment authorization, as required under the Immigration Reform and Control Act. I understand that my employment is terminable at-will, that I am not being employed for any specified time, and that this application is not and is not intended to be a contract for continued employment. If I am employed, I agree to abide by and observe all rules and regulations of the organization. I voluntarily authorize my former employers, schools and persons named herein to give information regarding me, whether or not such information is part of their records. I hereby release said organizations or persons from any liability or damages whatsoever for issuing this information.

Applicant Signature (Please type full signature)

Note: Employment decisions are made at each operating entity.

Applications will remain on file for one year and reviewed as appropriate openings occur.

  Attach your resume:
  Click browse and select the resume document that you wish to attach to your job application.