Employment Application

Sheppard Pratt is an Equal Opportunity Employer. We comply with all applicable laws of the State of Maryland and the federal government regarding employment practices. These statutes prohibit discrimination in employment based on race, creed, color, sex, age, national origin, occupation, personal appearance, political opinion, religion, marital status, or disability. We will provide assistance to individuals who because of their disability, need accommodations in the application process. Please advise the Human Resources Department if you need such assistance.

NOTE: When completing this application, please DO NOT use the ENTER/RETURN key to move forward, but rather the TAB key. Using the Enter/Return key will prematurely submit your application and necessitate restarting the application.

Last Name
First Name
Middle Int.
Email Address
Home telephone no.
Office telephone no.
Street Address
City
State
Zip
Social Security Number
Other name under which
you were previously employed
Position Applying For
Facility
Specify type of work desired
Specify days and hours
willing to work
When can you begin work?
Minimum acceptable salary
How did you find
out about this job?
Whom should we notify in case of emergency?
Name
Address
Phone
Relation

Are you legally authorized to work in the United States?
Are you under 21?
Note: Verification of your right to work in the United States will be required within three business days of your initial day of employment.
In the last three years, have you ingested or used any controlled substance or mind altering drug without its being lawfully dispensed to you or in your possession?
Have you ever had charges under the Office of the Inspector General that excludes you from providing services for Medicare/Medicaid?
If you selected 'Yes' for the above question, has reinstatement been granted?
Do you have an employment contract? If so, does it have any restrictions?
Please furnish all education and training
School/training Dates attended Year Graduated Subjects studied/degrees awarded

Please complete if licensure is required for position you are seeking
State License
Number 		Date of Original
Licensure 		Date of Most
Recent Renewal 		Expiration
Date
Information provided in response to these questions will not bar employment

If an answer to any of the following questions is "Yes," please give full details in comment box below.

1. Has your clinical license to practice in any jurisdiction ever been limited, suspended or revoked? 1:
2. Have your clinical privileges ever been suspended, diminished, revoked, or not renewed? 2:
3. Have you ever:
  • Received a probation before judgement?
    		•
  • Received a not criminally responsible disposition?
    		•
  • Are you currently the subject of any pending      criminal charges?
    		•
  • Have you been convicted?
    		•
    4. List name(s) of relative(s) employed at the hospital
    and department
           		 
    5. Have you ever applied for a position or been employed before at the member facilities? 5:
    6. If hired, will you consent to a physical examination at any time scheduled by your supervisor? 6:
    7. Were you in the United States Armed Forces? 7:
    Comment box for above questions.
    Employment History

    (List last employer first)
    Dates of
    employment     		From month, year

    To month, year
    Employers Name
    Employer's address
    Telephone no.
    Starting salary
    Ending salary
    Title and duties
    Supervisor's name, title,
    and telephone no.
    Reason for leaving
    Status worked

    Hours weekly:
    May we communicate with
    your present employer
    Dates of
    employment     		From month, year

    To month, year
    Employers Name
    Employer's address
    Telephone no.
    Starting salary
    Ending salary
    Title and duties
    Supervisor's name, title,
    and telephone no.
    Reason for leaving
    Status worked

    Hours weekly:
    Dates of
    employment     		From month, year

    To month, year
    Employers Name
    Employer's address
    Telephone no.
    Starting salary
    Ending salary
    Title and duties
    Supervisor's name, title,
    and telephone no.
    Reason for leaving
    Status worked

    Hours weekly:
    Dates of
    employment     		From month, year

    To month, year
    Employers Name
    Employer's address
    Telephone no.
    Starting salary
    Ending salary
    Title and duties
    Supervisor's name, title,
    and telephone no.
    Reason for leaving
    Status worked

    Hours weekly:
    Professional References

    (List only superiors or co-workers who would be in a
    position to comment specifically on your work performance.)
    Name:
    Present Title:
    Present Company:
    Present Company Address:
    Present Work Phone Number:
    Home Phone Number:
    Work Relationship To You:
    Dates of Work Relationship:
    Name:
    Present Title:
    Present Company:
    Present Company Address:
    Present Work Phone Number:
    Home Phone Number:
    Work Relationship To You:
    Dates of Work Relationship:
    Name:
    Present Title:
    Present Company:
    Present Company Address:
    Present Work Phone Number:
    Home Phone Number:
    Work Relationship To You:
    Dates of Work Relationship:

    PLEASE READ CAREFULLY:
    UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.

    Signature of applicant
    (Submission of this electronic application implies agreement)

    Release of Reference Information

    I hereby consent to Sheppard Pratt's obtaining information related to my application for employment with Sheppard Pratt from prior employers and other parties and hereby release all such persons from any liability whatsoever for supplying such information. I further agree to sign any release forms that may be required to obtain such information.

    Applicant Statement

    I affirm that all information I have supplied on this application and on all attached or enclosed documents is complete, factual, and truthful to the best of my knowledge. I understand and accept that any omissions, distortions, or misinformation given by me are grounds for my immediate dismissal from consideration for employment by Sheppard Pratt or termination from employment if I am hired by Sheppard Pratt.

    Conditions of Employment

    I fully understand and accept that any employment with Sheppard Pratt is contingent upon the following conditions:

    • I understand that any job offer may be conditioned on the results of a post-offer medical examination and/or responses to medical inquiries. I also understand that I will be required to pas a drug/alcohol screening test before being employed, and that such tests may also be required of me as an employee. I hereby consent to the foregoing and agree to execute any consent or other forms that may be required in connection therewith. I further confirm that I understand that my failure to cooperate with such requests will be grounds for denying me hire or, if I am hired, for my termination.

    • Receipt of satisfactory written references from present and past employers.

    • If requested, receipt of written verification of attendance dates, graduation, degrees/diplomas, certificates granted, research completed, and other pertinent information from each educational institution listed.

    • Signing of Sheppard Pratt’s policies acknowledgement and agreement form.

    • Satisfactory completion of a background records check for criminal convictions, probation before judgment, and/or pending charges with the CJIS and other such enforcement or investigatory agencies as Sheppard Pratt may deem appropriate.

    • Viewing of the Infection Control and/or Orientation Video, completion of the post-test, and attendance at New Employee Orientation.

    Employment Relationship

    I understand that nothing contained in this application or in the granting of an interview is intended to or shall constitute an employment contract between Sheppard Pratt and myself for either a specific term or for specific benefits. I further affirm that no such promises have been made to me elsewhere, orally or in writing.

    Applicant Certification Agreement

    I certify that the statements on this application are true and correct to the best of my knowledge and belief and hereby grant Sheppard Pratt permission to verify such answers. I understand that any false statement on this application my be considered as sufficient cause for rejection of this application for dismissal if such false statement is discovered subsequent to my employment.

    I authorize Sheppard Pratt to contact my prior employers and the educational institutions listed on this application. By my signature, (Submission of this electronic application implies agreement) I authorize those individuals and institutions to release all records regarding me, and to discuss my education and employment history with the Healthcare System representatives. I release Sheppard Pratt, my prior employers, and the listed educational institutions from all liability in connection with any such disclosure.

    I understand that I must complete this application fully in order to be considered for the job for which I am applying. I also understand that any offer of employment will be conditional on my passing a medical examination, which will include drug and alcohol tests. If I accept employment with Sheppard Pratt, I understand that it will be terminable at any time, at the will of either the Healthcare System or me, with or without notice. I further understand that I will be subject to Sheppard Pratt's policies and procedures during the period of my employment, and agree to abide by them.

    Signature of Applicant
    (Submission of this electronic application implies agreement)

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    Last modified: Tuesday, June 30, 2009

    Sheppard Pratt Health System
    6501 N. Charles Street
    Baltimore, MD 21285
    410-938-3000
    info@sheppardpratt.org

    Web Site Maintained by Sheppard Pratt Health System www.Sheppardpratt.org