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

All information must be completed even if resume is attached.

Date: Oct 31 2014 
PERSONAL
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 Memorial
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 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
Calendar

 
 End Date
Calendar

 

 Current

 Salary:
 Supervisor:  Tel. No. (- ext.
May we contact this employer? Yes No  If not, why?
 Start Date
Calendar

 
 End Date
Calendar

 

 Current

 Salary:
 Supervisor:  Tel. No. (- ext.
May we contact this employer? Yes No  If not, why?
 Start Date
Calendar

 
 End Date
Calendar

 

 Current

 Salary:
 Supervisor:  Tel. No. (- ext.
May we contact this employer? Yes No  If not, why?
 Start Date
Calendar

 
 End Date
Calendar

 

 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, including a criminal background check. 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.



Please Note: Care New England policy prohibits employees within the system to work at more than one operating unit at a time.


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.
  








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