• EQUAL OPPORTUNITY EMPLOYER

    Rome Memorial Hospital is an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, creed, color, religion, national origin, gender, age disability, sexual orientation, marital status, veteran status, or any other protected characteristic. Consistent with the Americans with Disabilities Act, applicants may request accommodations needed to participate in the application process.

    ROME MEMORIAL HOSPITAL EMPLOYMENT APPLICATION
        

    DATE:
    JOB INTEREST:
    SHIFT PREFERRED (Check all that apply)

                            


    Please indicate how you became aware of the vacant position. (check one)

                            


    GENERAL INFORMATION

    LAST NAME:
    FIRST:
    MIDDLE INITIAL
    STREET:
    CITY/STATE:
    ZIP:
    HOME PHONE:
    ALTERNATE PHONE:
    E-MAIL ADDRESS (REQUIRED):
    Have you ever been convicted of crime?

                           

    If yes, please explain:

    Have you ever been excluded or suspended from state or federal health care programs?

                          

    If yes, please explain
    :
    Have you previously worked for Rome Memorial Hospital?

                          

    If yes, please list dates:
    Are you over the age of 18? 

                          

    If not over 18, please state your age:
    Do you have working papers?

                          

    If hired, can you provide verification of identity and eligibility to work within 72 hours?

                         

    Are you eligible to work in the United States?

                         

    Do you have professional credentials or licensure for the position you have applied for?

                         

    Description of credentials and/or license identification number:
    Do you have a valid Driver's License?

                         

    State:
    Number:
    Do we need additional information about a name change, assumed name or nick name to check your work or education record?

                         

    If yes, please explain:
     
    When would you be available to work?
    Please list any proficiencies or special skills that you think may be helpful in your job interest.

     


    EDUCATIONAL INFORMATION   

     HIGH SCHOOL/GED:
    CITY/STATE:
    GRADUATED/GED? 

                        


    If no, are you currently enrolled?

                        


    TECHNICAL/VOCATIONAL:
    CITY/STATE:
    MAJOR:
    DEGREE:
    GRADUATED? 

                       

     



     COLLEGE:
    CITY/STATE:
    MAJOR:
    DEGREE:
    GRADUATED? 

                      

     



    GRADUATE SCHOOL: 
    CITY/STATE:
    MAJOR:
    DEGREE:
    GRADUATED?  

                     

       



    OTHER:
    CITY/STATE:
    MAJOR:
    DEGREE:
    GRADUATED?

                     

     


    EMPLOYMENT INFORMATION 

    Describe your employment history starting with your present or most recent employer. Please list all positions held and submit additional information if necessary via e-mail.
     

     May we contact your present employer? 

                    


    EMPLOYER:
    ADDRESS:
    PHONE:
    SUPERVISOR'S NAME:
    SUPERVISOR'S TITLE:
    POSITION HELD:
    EMPLOYED FROM    TO
    LAST SALARY: $ FULL TIME: PART TIME:    
    MAJOR JOB DUTIES:

    REASON FOR LEAVING: 

     

     



    EMPLOYER:
    ADDRESS:
    PHONE:
    SUPERVISOR'S NAME:
    SUPERVISOR'S TITLE:
    POSITION HELD:
    EMPLOYED FROM TO
    LAST SALARY: $ FULL TIME PART TIME
    MAJOR JOB DUTIES:

    REASON FOR LEAVING:

     



    EMPLOYER:
    ADDRESS:
    PHONE:
    SUPERVISOR'S NAME:
    SUPERVISOR'S TITLE:
    POSITION HELD:
    EMPLOYED FROM    TO
    LAST SALARY: $ FULL TIME       PART TIME
    MAJOR JOB DUTIES
     
    REASON FOR LEAVING:

     



    EMPLOYER:
    ADDRESS:
    PHONE:
    SUPERVISOR'S NAME:
    SUPERVISOR'S TITLE:
    POSITION HELD:
    EMPLOYED FROM   TO
    LAST SALARY: $ FULL TIME     PART TIME
    MAJOR JOB DUTIES:

    REASON FOR LEAVING:
       


    A cover letter and resume may be submitted in addition to this application by fax (315-338-7072), e-mail (jmarquette@romehospital.org), or by mail to: Rome Memorial Hospital, Human Resources Manager, 1500 N. James St., Rome, NY 13440.

    Will you be submitting a cover letter/resume in addition to the application?
     

              

      


    AUTHORIZATION

    By submitting this application:
     

    • I certify that the facts contained in this application (and accompanying documentation, if any) are true and complete to the best of my knowledge. I understand that any false statement, omission or misrepresentation on this application is sufficient cause for refusal to hire, or dismissal if I have been employed, no matter when discovered by the Hospital. 
    • I understand and agree that nothing contained in this application or conveyed during any interview is intended to create an employment contract. I further understand and agree that if I am hired, my employment will be "at will" and without fixed term and may be terminated at any time with or without cause and without prior notice, at the option of either myself or the Hospital. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the Hospital unless made in writing. I further understand that should an offer of employment be extended I will be required to submit to a Drug/Alcohol Test at the time of the Post-Offer Health Evaluation, a background check and finger printing, when applicable, pursuant to hospital policy. 
    • I understand that filling out this form does not indicate there is an open position and does not obligate the Hospital to hire. If hired, I agree to abide by all hospital work rules, policies and procedures. The Hospital retains the right to revise its policies or procedures, in whole or in part, at any time. 
    • I further understand that Rome Memorial Hospital is a tobacco-free campus. The use of any tobacco product is prohibited on Hospital owned and Hospital operated property.
       
    REFERENCES RELEASE AUTHORIZATION
    • Please respond to this Reference Release Authorization Form and provide information as to my suitability for employment at Rome Memorial Hospital.  
    • By this authorization, I hereby release you from any and all liability for providing the records and information identified below, regardless of the actual truth or falsity thereof.  
    • I hereby authorize the release of my employment dates, evaluations of work performance, attendance records, and any other work-related information to Rome Memorial Hospital. 
    • I authorize the Registrar/Guidance Office to release my educational transcript and any other Information in my educational records to Rome Memorial Hospital. 
    • I hereby authorize Rome Memorial Hospital to receive and have full access to the records set forth above, and release Rome Memorial Hospital and its officers, employees, and agents from any and all liability from damage which may result from obtaining, reviewing or considering such documents or date. 
    • I am voluntarily furnishing the identifying information listed below to assist you in locating my records.

       

    AUTHORIZATION OF REFERENCES (FULL NAME):
    DATE: