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Westchester General Hospital and Southern Winds Hospital are accredited by the Healthcare Facilities Accreditation Program (HFAP) of the American Osteopathic Association (AOA). Click on the logo below for further information on our HFAP Seal of Excellence accreditation status.

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I. Personal Information

Step 1 of 8.


First Name
Middle Initials
Last Name
Other name by which you have been known
Present Street Address
City
State (2 character code)
Zip Code (xxxxx)
Phone # (xxx-xxx-xxxx)
Cellular Phone (xxx-xxx-xxxx)
SSN (xxx-xx-xxxx (use 0's if foreign))
Beeper:
Email Address
Are you 18 years of age or older?	YesNo
Do you have a legal right to work in the US?	YesNo
How did you learn about us?	Newspaper ad Other publication Hospital employee Other
Specify from above:
Have you previously been employed by any of the following facilities?	Southern Winds Hospital Westchester General Hospital
If so, in what capacity?
Date Employed From: (mm/dd/yyyy)
Date Employed To: (mm/dd/yyyy (leave empty if still employed))

List any relatives who are currently employed by our facility.

Relative 1
Relative Name
Relationship
Department:

Relative 2
Relative Name
Relationship
Department

Relative 3
Relative Name
Relationship
Department

Have you ever voluntarily relinquished your license or certification?	YesNo
Have you ever been convicted of a crime other than a minor traffic violation?	YesNo
Have you ever had your license or certification in any jurisdiction limited, suspended, revoked, or voluntarily relinquished?	YesNo

Please Note: A criminal conviction is not an absolute bar to employment but will be considered in relation to specific job requirements.

II. Employment Desired

Step 2 of 8.


Desired Position
Location Desired
How often can you work?	Full-Time Per Diem Pool Part-Time
When can you work?	Day Evening Night
Can you work weekends?	YesNo

III. Employment Record

Step 3 of 8.


Employer 1

Employed From: (mm/dd/yyyy)
Employed To (mm/dd/yyyy (leave empty if still employed))
Employer Name
Employer Address
Employer City
Employer State (2 character code)
Employer Zip Code (xxxxx)
May we contact?	YesNo
Employement Status:	Full-TimePart-TimeAs Needed
Last Salary
Job Title
Describe principal duties or responsibilities: (255 characters)
Reasons For Leaving: (255 characters)

Employer 2

Employed From: (mm/dd/yyyy)
Employed To (mm/dd/yyyy (leave empty if still employed))
Employer Name
Employer Address
Employer City
Employer State (2 character code)
Employer Zip Code (xxxxx)
May we contact?	YesNo
Employement Status:	Full-TimePart-TimeAs Needed
Last Salary
Job Title
Describe principal duties or responsibilities: (255 characters)
Reasons For Leaving: (255 characters)

Employer 3

Employed From: (mm/dd/yyyy)
Employed To (mm/dd/yyyy (leave empty if still employed))
Employer Name
Employer Address
Employer City
Employer State (2 character code)
Employer Zip Code (xxxxx)
May we contact?	YesNo
Employement Status:	Full-TimePart-TimeAs Needed
Last Salary
Job Title
Describe principal duties or responsibilities: (255 characters)
Reasons For Leaving: (255 characters)
Employer 4

Employed From: (mm/dd/yyyy)
Employed To (mm/dd/yyyy (leave empty if still employed))
Employer Name
Employer Address
Employer City
Employer State (2 character code)
Employer Zip Code (xxxxx)
May we contact?	YesNo
Employement Status:	Full-TimePart-TimeAs Needed
Last Salary
Job Title
Describe principal duties or responsibilities: (255 characters)
Reasons For Leaving: (255 characters)

IV. Education History

Step 4 of 8.


High School Name:
High School City
High School State (2 character code)
Graduation Date (mm/dd/yyyy)
Is this a GED?	YesNo

College 1

College Attended
College City
College State (2 character code)
Years Attended
Did you graduate	YesNo
Diploma/Degee
Course Of Study

College 2

College Attended
College City
College State (2 character code)
Years Attended
Did you graduate	YesNo
Diploma/Degee
Course Of Study

V. Professional Licensure, Registry, Certification

Step 5 of 8.

The State of Florida regulations and the mandate of the Joint Commission for Accredited Healthcare Organizations require that all registered, licensed and certified employees show proof of same to his/her employer. Copy required upon employment.



License 1
Type of license
Issuing State or organization
License Number
Expiration Date: (mm/dd/yyyy)

License 2
Type of license
Issuing State or organization
License Number
Expiration Date: (mm/dd/yyyy)

License 3
Type of license
Issuing State or organization
License Number
Expiration Date: (mm/dd/yyyy)

If not currently registered, licensed, or certified, are you eligible?	YesNoNot applicable
When will you/ did you sit for you examination? (mm/dd/yyyy)

VI. Office Skills

Step 6 of 8.

Select all that apply	Personal Computer Typing Medical Terminology
Hardware Used
Software Used
Other Special Skills

VII. Foreign Languages

Step 7 of 8.

Language 1
Language
Speak	FluentGoodFair
Read	FluentGoodFair
Write	FluentGoodFair

Language 2

Language
Speak	FluentGoodFair
Read	FluentGoodFair
Write	FluentGoodFair

Language 3

Language
Speak	FluentGoodFair
Read	FluentGoodFair
Write	FluentGoodFair

VIII. Applicant's Certification and Agreement

Step 8 of 8.

PLEASE READ CAREFULLY BEFORE SUBMITTING THE APPLICATION

I certify that the information contained in this application is correct to the best of my knowledge and understand that any falsification, misrepresentation or omission on this application is grounds for refusal to hire, or if hired, dismissal. I authorize any of the persons or organizations referenced in this application to give the Hospital any personal or otherwise, information with regard to any of the subjects covered by this application and release of such parties and the Hospital from all liability for any damage that may result from furnishig such information. I further authorize the Hospital to conduct any background investigation(s) thy deem necessary. I authorize the Hospital to request and receive such information.

If employed, I understand that I will be an employee "at will" and either the Hospital or I may terminate my employment relationship at any time with or without notice for any reason not violative of the law.

I agree to comply with the Hospital rules, regulations and policies, and acknowledge that these rules, regulations and policies may be changed, interpretation withdrawn, or supplemented any time and without prior notice to me.

I acknowledge that any offer of employment, or my acceptance of an employment offer, if such is to occur, may be withdrawn with or without cause and with or without prior notice at any time, at the option of the Hospital or myself. I understand that this application and any other documents which I may receive are not contracts of employment. I further understand that no representative of the Hospital other than the Chief Executive Officer has any authority to enter into any agreement for employment for any specified period of time or to assure any other personnel action, either prior to commencement of employment or after I have become employed, or to assure any benefits or terms and conditions of employment, or make any agreement contrary to the foregoing.

I agree to have a physical examination as required for my position and understand that any offer of employment is contingent upon my passing this physical examination.

I understand that the signature below shall have the same legal effect as if made under oath.




Signature (type name in full)
Social Security Number: (xxx-xx-xxxx)

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