Welcome to Four Winds Hospitals

Employment Application

An Equal Opportunity Employer

We consider applicants for all positions without regard to race, color, religion, sex, national origin, ancestry, age, physical or mental disability, sexual orientation or military or veteran status.

Personal Info
*Date:  
*First Name: *Last Name:
Middle Name:
*Address 1:
Address 2:
*City: *State: *Zip:
*Primary Phone: - - *Type:
Secondary Phone: - - Type:
Email:  
If you are under 18 years of age, do you have a work permit:
* Are you either a US Citizen or an Alien who has the legal right to remain and work in the US? (Proof of citizenship or immigration status will be required upon employment)


*Type of position desired:
Full Time Part Time Summer Temporary
Other, please list:
*Salary requirements: *Date available to start:


*Have you filed an application with Four Winds before?
If Yes, give a date:
*Have you ever been employed at Four Winds before?
If Yes, give date:

Referral Source: (Check all that apply)
Advertisement Friend Walk-In Relative
Other, please list:


In accordance with NY Law, you may be required to submit fingerprints prior to employment.
*Have you ever been convicted of a crime or are there any pending charges against you?*
If yes, please explain:
*In accordance with New York State Law, Four Winds Hospital will check the Staff Exclusion List (SEL) prior to employment. Are you listed on the Staff Exclusion List?

Employment History
(List most recent employer first)
*May we contact your current employer for a reference?

*Employment 1 (most recent)

*Company Name:
Address:
*City: *State: Zip:
*From: *To:
*Responsibilities:
Business: Supervisor:
*Reason(s) for leaving:

Employment 2

Company Name:
Address:
City: State: Zip:
From: To:
Responsibilities:
Business: Supervisor:
Reason(s) for leaving:

Employment 3

Company Name:
Address:
City: State: Zip:
From: To:
Responsibilities:
Business: Supervisor:
Reason(s) for leaving:

Education

High School/Prep School
*Name: *Location:
*From: *To: *Years completed: *Graduated:
Major: *Degree Received:

Vocational/Trade School
Name:
Location:
From:
To:
Years completed:
Graduated:
Major:
Degree Received:

College
Name:
Location:
From:
To:
Years completed:
Graduated:
Major:
Degree Received:

Graduate School
Name:
Location:
From:
To:
Years completed:
Graduated:
Major:
Degree Received:

Other
Name:
Location:
From:
To:
Years completed:
Graduated:
Major:
Degree Received:
Do you currently have Licensure and/or Certification in your professional field?
If Yes, please list area of specialty and License or Certificate number (proof of License/Certification will be required on hire):




Skills/Affiliations/Certifications
List any professional or business organizations you are affiliated with that you wish us to consider when evaluating your application:


Office Skills: (Check all that apply)
Computer List Type(s)
Other (list)

List additional experiences related to the position for which you have applied and did not list in the employment section of application. These may be paid or volunteer positions:


The facts set forth in my application for employment are true and complete and I authorize investigation of all statements contained within. I understand that if employed, any misstatements, falsification or omission of facts shall be considered sufficient cause for dismissal.
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