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.
*Except for minor traffic violations, have you ever been convicted of a crime or are there any pending charges against you?*
If yes, please explain:
* A "Yes" answer is NOT an automatic disqualification to employment. Each response will be reviewed on an individual basis in relation to ability to perform job duties.
*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:
* Proof of highest post-secondary degree must be provided by the applicant.
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:


List certifications you have obtained:

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:

Please upload your resume and cover letter. Files must be in Word or PDF format.
Resume:
Cover letter:


APPLICANT'S STATEMENT

I understand that Four Winds Saratoga must conduct a New York Central Registry for Child Abuse and Neglect clearance on all employees. I understand that I must complete and sign a consent form giving Four Winds Saratoga permission to conduct a background search.

I give Four Winds Saratoga permission to contact all or any of my previous employers and references and authorize them to provide all information requested of them by Four Winds Saratoga unless qualified above. After an offer of employment has been made, I agree to take job - related medical examination through Four Winds Saratoga Medical Clinic. I understand that this examination can be performed by my physician at my expense with the findings reported to Four Winds Saratoga. I understand that any offer of employment is conditional upon receipt of satisfactory references and background check as well as completion of such job - related medical examination that indicates that I can perform the essential functions of the job for which I am being considered.

I have provided truthful and complete responses to all inquires in the application and understand that the discovery of any falsification or omission constitutes grounds for immediate dismissal.
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