NFMMC Employment Application
Please complete our online application to the best of your ability. Your application will be reviewed by our recruiting staff and we will contact you soon, should we feel that your background meets our current needs.
Applicant Personal Information
I am applying for the following position
*
Indicate the position for which you would like to be considered. View Physician Oppourtunities or General Opportunities.
First Name
*
Middle Name
Last Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
*
example@example.com
Social Security Number
How did you hear of this position?
*
Please Select
Employee Referral
Walk In
Monster.com
Career Builder
Job Fair
Temp Agency
College Relations
Open House
Externship
Ad
Community or other Agency
Other
Additional Information
If ad, friend, relative, job fair or other, specify
Employment Information
Date Available for Work
*
-
Month
-
Day
Year
Date
Type of Employment Desired
No preference
Full-Time
Part-Time
PRN
Weekend
Overnight
Temporary
Summer
Per Diem
Shifts willing to work
*
Day
Evening
Night
Indicate the days of week you are willing to work
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Employment Eligibility
Are you legally authorized to work in the US?
*
Yes
No
Are you 18 years of age or older?
*
Yes
No
Have you ever been offered a position OR employed at Niagara Falls Memorial Medical Center / Schoellkopf Health Center?
*
Yes
No
Are you related to anyone employed here?
Yes
No
Can you perform the essential functions of the job for which you are applying with or without reasonable accommodations?
*
Yes
No
Education
Enter Name & Location of all High Schools, Vocational Schools, Business Schools, Colleges, and Related Military Courses attended.
High School
Name
City
State
Zip
Course/Study
Years Completed
Graduate?
Yes
No
College
Name
City
State
Zip
Course/Study
Years Completed
Graduate?
Yes
No
Degree
Other Trade, Business, Night or Correspondence School, or Military
Name
City
State
Zip
Course/Study
Years Completed
Graduate?
Yes
No
Degree
To enable a check of your school and work records, have you attended school or worked under any other name(s)?
*
Yes
No
Professional License or Registration
If you have a Professional or Technical License, Registration, Certification, or Permit complete the following:
Type 1
Issued By
State Issued
Number
Expiration
Type 2
Issued By
State Issued
Number
Expiration
Do you possess the required licensure for this position?
If so, please provide the type, number, issued by, state, date issued, and expiration date.
List any licenses/certificate that you current possess (i.e., CNA, LPN, ALCS, BLS, CCRN, etc.):
Please provide the type, number, state, date issued, and expiration date.
Has any licensing/disciplinary authority revoked, annulled, cancelled, accepted surrender or suspended, placed on probation or refused to issue or renew a professional licensure or certificate held by you now or previously?
Yes
No
Are any charges pending against you in any jurisdiction for any sort of professional misconduct?
Yes
No
References
Please provide at least three (3) professional references (i.e., former/current supervisors, coworkers, professors, etc.)
Reference 1
Name
Relationship
Telephone
Email Address
Reference 2
Name
Relationship
Telephone
Email Address
Reference 3
Name
Relationship
Telephone
Email Address
Reference 4
Name
Relationship
Telephone
Email Address
Experience
Starting with your present or most recent employer, including summer employment. If space is insufficient; list on an additional page or attach resume. All data must be completely filled in. DO NOT write "see resume".
Employer 1
Company Name
Phone
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employed From
Employed To
Name/Title of Immediate Supervisor
Job Title
Nature of Experience: describe your work/responsibilities
Reason for Leaving
May we contact the employer?
Yes
No
Employer 2
Company Name
Phone
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employed From
Employed To
Name/Title of Immediate Supervisor
Job Title
Nature of Experience: describe your work/responsibilities
Reason for Leaving
Employer 3
Company Name
Phone
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employed From
Employed To
Name/Title of Immediate Supervisor
Job Title
Nature of Experience: describe your work/responsibilities
Reason for Leaving
Employer 4
Company Name
Phone
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employed From
Employed To
Name/Title of Immediate Supervisor
Job Title
Nature of Experience: describe your work/responsibilities
Reason for Leaving
May we contact your present employer?
Yes
No
Have you ever been terminated by an employer?
Yes
No
If yes, please explain:
Have you ever resigned in order to avoid termination?
Yes
No
If yes, please explain:
Essential Functions of Position
Are you able to perform the essential functions of the job with or without reasonable accommodation?
Yes
No
Conviction or Pending Criminal Charge
*Please note that answering Yes to either of these questions does not automatically bar you from consideration.
Have you ever been convicted of a crime other than a minor traffic offense (not including sealed records or youthful offender adjudications)?
Yes
No
Are you currently charged with any unresolved pending criminal charge?
Yes
No
Release
I hereby declare that all the above statements are true and correct to the best of my knowledge, and authorize Niagara Falls Memorial Medical Center and /or Schoellkopf Health Center to inquire into all matters contained in this application including my educational and work records, with the understanding that any misrepresentation or omissions made herein will be just and due cause for my discharge from employment. I understand that I may be rejected for employment and may be discharged for falsifying or misrepresenting any information contained in this employment application, pre-employment physical or during the interview process. I may be terminated regardless of when the falsification or misrepresentation is discovered. I release all organizations, schools, or persons providing information relevant to my employment qualifications from all liability for any ensuing damages. I understand that nothing contained in this application or in the granting of an interview is intended to create an employment contract of any kind. I also certify that I understand that if hired, my employment is at will and can be terminated by Niagara Falls Memorial Medical Center and/or Schoellkopf Health Center, or me at any time for any reason.
*
As part of Niagara Falls Memorial Medical Center/Schoellkopf Health Center’s effort to provide a safe and healthy work environment free from alcohol and drug abuse, all applicants who are being considered for employment will be required to undergo a drug screening before an employment decision is made. A positive test result will make an applicant ineligible for employment. I understand that ineligibility for employment is neither defined nor time limited.
*
I agree to submit to a Post Job Offer Physical and I also realize that as an applicant I may be asked to provide a sample of my hair, urine and/or blood and consent to such testing for drugs and alcohol. Satisfactory completion of the Post Job Offer Physical and any other Physical Examination (i.e. drug and alcohol tests) is required for employment.
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Reference Checking Consent and Authorization Form
I have applied for employment at Niagara Falls Memorial Medical Center and /or Schoellkopf Health Center and have provided information about my previous employment. I authorize Niagara Falls Memorial Medical Center/Schoellkopf Health Center to conduct a reference check with my present and/or previous employer(s). I understand that reference information may include, but not be limited to, verbal and written inquiries or information about my employment performance, professional demeanor, rehire potential, dates of employment, salary and employment history.My signature below authorizes my former or current employers and references to release information regarding my employment record with their organizations and to provide any additional information that may be necessary for my application for employment at Niagara Falls Memorial Medical Center/Schoellkopf Health Center, whether the information is positive or negative. I knowingly and voluntarily release all former and current employers, references, and Niagara Falls Memorial Medical Center/Schoellkopf Health Center from any and all liability arising from their giving or receiving information about my employment history, my academic credentials or qualifications, and my suitability for employment with Niagara Falls Memorial Medical Center/Schoellkopf Health Center.I further authorize Niagara Falls Memorial Medical Center/Schoellkopf Health Center to obtain feedback and references from my supervisors over the course of my employment with Niagara Falls Memorial Medical Center/Schoellkopf Health Center. I understand that subsequent and continued employment with Niagara Falls Memorial Medical Center/Schoellkopf Health Center may be subject to this feedback. This form may be photocopied or reproduced as a facsimile, and these copies will be as effective as a release or consent as the original which I sign.
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Upload Your Resume
Your resume file must be less than 2 MB and must be one of the following file formats: doc, docx, rtf, txt, pdf.
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