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Other Last Name(s):
Lao Democratic Republic
Papua New Guinea
Saint Vincent Grenadines
Sao Tome and Principe
Trinidad and Tobago
United Arab Emirates
How did you hear about us?
Association of Fundraising Professionals
California Association of Nonprofits
California Healthcare News
Council on Foundations
Journal or Publication
Other (Please Specify)
Work For Good
Other (Specify Source):
If you selected
"Employee Referral" in the source box above please list our employees name in the "Referred By" box below.
Are you applying for: (select all that apply)
On Call, Varying Hours & Days
What days and hours are you available for work?
Days & Hours Available:
Would you be available to work overtime, if necessary?
Available to work OT?:
If you are offered a position, are you able to provide proof of U.S. Citizenship or proof of your legal right to work in the U.S.?
Proof of U.S. Citizenship:
Are you at least 18 years of age?
At least 18?:
If “no”, you must be able to verify that you meet minimum legal age requirements.
Have you ever been employed with The Health Trust, (Good Samaritan Health Systems previously Health Dimensions. Inc.) or Good Samaritan Hospital, San Jose Medical Center, Mission Oaks Hospital, South Valley Hospital or Sereno Surgery Center?
Employed with us before?:
If yes, Dates:
If yes, Position(s):
If yes, Affiliate(s):
Do any relatives currently work for this company?
Relatives working here?:
If yes”, then please state the name(s) and relationship(s).
If yes, Details:
Are you currently excluded from participation in any federally funded healthcare program – including Medicare and Medicaid – and are you aware of any potential exclusion from a federally funded health program.
Have you ever been convicted of, or pleaded guilty or “no contest” to, any crime*?
Convicted of a Crime?:
If yes, state the nature of the offense, where and when it occurred, and the sentence imposed.** Please provide any further information you would like us to know.
* Applicants do not have to answer “yes” for or include information about:
(1) any arrest that did not lead to a conviction, however, you must provide information concerning any arrest for which you are currently out of jail on bail or on your own recognizance pending trial;
(2) any conviction, release from incarceration, or completion of probation that occurred seven or more years ago;
(3) any misdemeanor conviction for marijuana-related offenses that occurred two or more years ago;
(4) any conviction for which the record has been judicially ordered sealed, expunged, or statutorily eradicated;
(5) any misdemeanor conviction for which probation has been successfully completed or otherwise discharged and the case has been judicially dismissed; or
(6) any referral to, and participation in, any pretrial or post-trial diversion program.
**Applicants will not be denied employment solely because of a conviction for a criminal offense. The Health Trust will take into consideration the nature and seriousness of the offense, when the offense occurred, the circumstances surrounding the offense, and whether the offense adversely affects the applicant’s ability to legally or effectively perform the duties of the position for which the applicant applied.
If yes, Details:
Are you currently out on bail or released on your own recognizance pending trial?
Bail or trial pending?:
If offered a position with this company, do you have reliable transportation to and from work?
Do you possess a current/active drivers license?
Current/Active Driver Lic:
After reviewing the job description, are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?
If no, describe the functions that cannot be performed.
If no, Details:
Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants / employees to perform essential functions. Depending on the position, employees may be required to have a job-related, post-employment offer medical examination.
Licenses or Certificates - Have you ever been granted a Professional License or Certificate?:
Additional Education Information
Additional Education or Training
Education or Training:
Are you fluent in any foreign language? If yes, please list language(s):
Other skills (computer training, software applications, equipment, techniques, etc)
Employment History - Please provide a complete list of your work history for the last ten years, including periods of unemployment.:
Professional References - below, professional references, not related to you, whom we may contact.:
Your resume can be uploaded in any of the following formats: DOC, DOCX, RTF, PDF, TXT, HTML.
Add Resume & Attachments
You can use the text area for a cover letter and any supplementary information you would like to provide about your career goals, availability, best times to contact you, etc.
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY BEFORE SIGNING:
I certify that the information contained in this application and any attachments is true and correct to the best of my knowledge. I consent to having any of the information verified by the company. I authorize my references and supervisors to provide information concerning my previous and/or present employment. I release all parties from any and all liability for damages that may result from furnishing such information, as well as from the use of or disclosure of such information by the company or its agents. I understand that any misrepresentation or material omission in this application may result in my failure to receive an offer or, if I am hired, in my dismissal.
I UNDERSTAND AND AGREE THAT IF I AM HIRED, MY EMPLOYMENT CAN BE TERMINATED AT WILL, WITH OR WITHOUT CAUSE, AT ANY TIME, EITHER AT MY OPTION OR AT THE OPTION OF THE COMPANY. No representative of the company other than the Chief Executive Officer has any authority to agree to the contrary. Further, the Chief Executive Officer may not alter the at-will nature of the employment unless done so specifically in a written agreement signed by both of us.
I understand that any offer of employment is contingent on the satisfactory results of an employment reference check, as well as the satisfactory results of a criminal background investigation, sexual offender check and driving record check. Appropriate automobile insurance and may also be required. A fingerprint check through the Department of Justice and Federal Bureau of Investigation may be required by a position and Tuberculosis screening. All HIPAA regulations are adhered to by The Health Trust. The Health Trust will follow all State and Federal requirements regarding Criminal Offender Record Information.
I further understand that all offers of employment are contingent upon on my providing satisfactory proof of my identity and legal authority to work in the U.S. in accordance with the Immigration Reform Control Act of 1986
Any additional comments you would like to provide:
Please type your full legal name in the "Electronic Signature" box below. This will serve as your full agreement and understanding of the statements above.
Format: M/D/YY *
Voluntary Identification Form
Equal Opportunity Employers are required by the Federal Government to provide statistical information about applicants and employees to demonstrate that we meet equal opportunity requirements.
In an effort to comply with the government record keeping requirements, we ask that you complete this information. The information that you choose to provide will be kept in a separate file and will not be used in any hiring or other employment decisions. Any information you provide will be held in the strictest of confidence. voluntarily
Choose Not to Disclose
Hispanic or Latino
White (not Hispanic or Latino)
Black or African American (not Hispanic or Latino)
Native Hawaiian or Other Pacific Islander (not Hispanic or Latino)
Asian (not Hispanic or Latino)
American Indian or Alaska Native (not Hispanic or Latino)
Two or More Races (not Hispanic or Latino)
Choose Not to Disclose
Federal regulations require us to provide equal opportunity to disabled persons. If you believe you are covered by these regulations and wish to receive consideration under them, please check below.
Other Protected Veterans
Armed Forces Service Medal Veterans
Recently Separated Veterans
Choose Not to Disclose
Self - Identification Description
VIETNAM VETERAN – Use the following definitions to identify yourself as a Vietnam Veteran.
1. If you served on active duty for a period of more than 180 days, any part of which occurred during August 6, 1964 to May 7, 1975, and were discharged or released from that duty with other than a dishonorable discharge OR
2. If you were discharged or released from active duty for a service connected disability and any part of that active duty was performed during August 6, 1964 to May 7, 1975.
DISABLED VETERAN – Use the following definitions to identify yourself as a Disabled Veteran.
1. If you are entitled to disability compensation under laws administered by the Veterans Administration for a disability, (i.e., disabilities rated at 30 percent or more, or at 10 or 20 percent if the veteran has been determined to have a serious employment handicap), OR
2. If you were released or discharged from active duty for a disability incurred or aggravated in the line of duty.
RECENTLY SEPARATED VETERAN - Use the following definitions to identify yourself as a Recently Separated Veteran.
1. Any veteran who served on active duty in the U.S. military, ground, naval, or air service during the one year period beginning on the date of such veteran’s discharge or release from active duty.
OTHER PROTECTED VETERAN
1. Any other veteran who served on active duty in the U.S. military, ground, naval, or air service during a war or in a campaign or expedition for which a campaign badge has been authorized, other than a special disabled veteran, veteran of the Vietnam era, or recently separated veteran.
DISABLED - Use the following definitions to identify yourself as disabled.
1. If you have an impairment (physical or mental) which substantially limits one or more of your major life activities. (A major life activity is any mental or physical function that, if impaired, creates a substantial barrier to employment.)
2. If you have a record of such an impairment.
3. Or, if society regards you as having such an impairment.