Apply Online - Rockcastle Regional Hospital

All statements made by applicants for employment on this application form will be checked for accuracy. We offer equal employment opportunities to all persons without discrimination on the basis of race, color, religion, age, sex, national origin, citizenship status, physical or mental disability, or past, present or future service in the uniformed Services of the U.S., or any other legally protected status. The use of this form does not mean there are positions open and does not obligate us in any way.

We are proud to be a DRUG-FREE workplace. Screening tests for alcohol and illegal drug use may be required post offer and during employment. For this type of employment State Law requires a criminal record check as a condition of employment.

I understand*

Yes

Equal Opportunity Employer

If you would like to print a paper application and send it to us, you may do so by downloading the PDF form here.

All fields are required to be completed. If a question does not apply, type “not applicable” or “N/A” in the space provided. This demonstrates you have read and completed the application in its entirety.

Personal Information

First Name*

Last Name*

Home or Best Phone Number*

Emergency Phone Number*

Email*

Social Security Number*

Professional License/Certification Number (if applicable)

Present Address

Street Address*

Address Line 2

City*

State*

Postal/Zip Code*

Previous Address - If at present address less than one year, please give previous address.*

Are you at least 18 years of age? Employment is subject to verification of minimum legal age.*

Yes

No

Can you produce documented proof of your identity and eligibility for employment in the United States? Examples: driver's license, Social Security card, birth certificate, and/or Immigration and Naturalization Service Documents.*

Yes

No

MUST indicate specific job applied for. Applications stating "any", "all", etc., will not be processed.

Position Applying For (select one)*

If "Other" please list

Rate of pay expected*

How soon could you report to work?*

Type of employment desired*

Full-Time

Part-Time

Temporary

PRN

What days and hours, if part time?

Days

Hours

All fields are required to be completed. If a question does not apply, type “not applicable” or “N/A” in the space provided. This demonstrates you have read and completed the application in its entirety.

Elementary/Middle School Name*

Elementary/Middle School Address*

Check last year completed*

5

6

7

8

N/A

High School Name*

High School Address*

Check last year completed*

9

10

11

12

N/A

Did you graduate?*

Yes

No

GED

College Name*

Major*

Show Degree*

College Address*

Check last year completed

1

2

3

4

N/A

College Graduate*

Yes

No

N/A

Post Graduate School Name*

Major*

Graduate School Graduate*

Yes

No

N/A

Post Graduate School Address*

Show Degree*

Have you applied for a job with us before?*

Yes

No

Have you interviewed for a job with us before?*

Yes

No

Have you ever worked for us before?*

Yes

No

How did you come to apply? (select one)*

Other

Have you ever been bonded?*

Yes

No

Have you ever refused a bond?*

Yes

No

If Yes, state a reason and date.*

Have you ever been convicted of a violation of the law except a minor traffic violation? A conviction will not necessarily disqualify you from employment.*

Yes

No

If yes, state date, court, and place where offense occurred.

Have you ever been discharged or requested to resign from a position?*

Yes

No

Are you employed now?*

Yes

No

If yes, may we contact your present employer?*

Yes

No

Why do you desire to make a change?*

Have you ever held a position of trust (handling money or confidential material)?*

Yes

No

If yes, describe:

Do you have any reason to believe that you would have difficulty meeting this facility's work schedules or the duties of the position you are applying for?*

Yes

No

If yes, explain:

Prior Work Record Start with most recent or present employer and complete in full. All fields are required to be completed. If a question does not apply, type “not applicable” or “N/A” in the space provided. This demonstrates you have read and completed the application in its entirety.

Employer 1

Name*

Address*

Phone*

Immediate Supervisor (Name & Position)*

Date Hired*

Date Left*

Starting Rate*

Last Rate*

Job Title*

Duties*

Reason for Leaving*

May we contact this employer?*

Yes

No

Employer 2

Name*

Address*

Phone*

Immediate Supervisor (Name & Position)*

Date Hired*

Date Left*

Starting Rate*

Last Rate*

Job Title*

Duties*

Reason for Leaving*

May we contact this employer?*

Yes

No

Employer 3

Name*

Address*

Phone*

Immediate Supervisor (Name & Position)*

Date Hired*

Date Left*

Starting Rate*

Last Rate*

Job Title*

Duties*

Reason for Leaving*

May we contact this employer?*

Yes

No

Personal References - Do Not List Relatives or Former Employers

Reference 1

First Name*

Last Name*

Address*

Phone*

Reference 2

First Name*

Last Name*

Address*

Phone*

Reference 3

First Name*

Last Name*

Address*

Phone*

Job Applicant's Agreement and Certification

"I certify that the information given by me in this application is true in all respects, and I agree that if the information given is found to be false in any way, it shall be considered sufficient cause for denial of employment or discharge. I authorize the use of any information in this application to verify my statements, and I authorize past employers, all references, and any other persons to answer all questions asked concerning my ability, character, reputation, and previous employment record. I release all such persons from any liability or damages on account of having furnished such information."*

I agree

"I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between the facility and myself for either employment or the providing of any benefit. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the facility. If an employment relationship is established, I understand that I have the right to terminate my employment at any time and that the facility retains the same right."

"If I am offered employment, I agree to submit to a physical examination whenever requested, and I understand my becoming employed and/or my continued employment are subject to the results of any physical examination related to my job duties in accordance with facility policies and procedures." (Physical exam includes post offer pre-employment physical, as well as functional capacity screening.)

"I understand that if employed, policies and rules which are issued are not conditions of employment and that the employer may revise policies or procedures, in whole or in part, at any time."

"I understand that this application will be kept on active file for three (3) months from the date completed, after which time I would have to reapply in accordance with established facility procedures."*

I agree

I have read the Rockcastle Regional Hospital and Respiratory Care Center’s Behavior Standards, and if offered employment agree to comply with these Behavior Standards. (Click here to read Behavior Standards) Click here to read Behavior Standards*

I agree

Agreement statement:
I agree to the confirmation statement with my electronic signature:*

HP Name

Rockcastle Regional Employment Application

Equal Opportunity Employer

Personal Information

Present Address

MUST indicate specific job applied for. Applications stating "any", "all", etc., will not be processed.

What days and hours, if part time?

All fields are required to be completed. If a question does not apply, type “not applicable” or “N/A” in the space provided. This demonstrates you have read and completed the application in its entirety.

Prior Work Record Start with most recent or present employer and complete in full. All fields are required to be completed. If a question does not apply, type “not applicable” or “N/A” in the space provided. This demonstrates you have read and completed the application in its entirety.

Employer 1

Employer 2

Employer 3

Personal References - Do Not List Relatives or Former Employers

Reference 1

Reference 2

Reference 3

Job Applicant's Agreement and Certification