River Parishes Hospital, Welcome to River Parishes Hospital

Online Application for Employment
A7940-LP 03/03

It is the policy of this facility to provide equal opportunity to persons regardless of race, religion, age, gender, disability, national origin, color, or any other classification in accordance with federal, state and local statutes, regulations and ordinances.

Applicant Name (please give complete name)	This application to be active for a period of days only.
First Middle Last	Are you at least 18 years old? Yes No	Social Security No.	Home Phone
Present address (Include City, State, Zip Code)
Previous address (Include City, State, Zip Code)		Email address:

Current Open Position(s) for Which You Are Applying

Type of Position
Per Diem Full Time Part Time	Pool PRN Temporary

Shift
Day Evening	Weekend Night Rotation

Salary Required

Are you Willing to:
Travel Relocate Travel and Relocate

Do You have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?
Yes No

If overtime work is required periodically, does this pose a problem for you?
Yes No

Date Available for Work

Are You Legally Authorized to Work in the U.S.?
Yes No

Have you ever worked at this facility or in a facility associated with LifePoint Hospitals, Inc.?
Yes No

If yes, what facility?

Are you related to another facility employee?
Yes No

How did you learn about this position?
State Employment Commission
Agency Job Listing Current Employee Ad	School Job Line Internet Other

Are you able to perform the essential, job related functions for which you are applying with or without accommodations?
Yes No

Have you been convicted of a crime and/or released from confinement following a conviction of any criminal offense? Arrests or charges that have been expunged need not be disclosed.
Yes No
If Yes, give date, place and nature of each such conviction.

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?
Yes No

Educational History
Type of School	Name of School City, State	Check the Last Year Attended	If Graduated Degree or Certificate Awarded
High School/ GED		9 10 11 12
College		1 2 3 4
Graduate School		1 2 3 4
Other		From Year/ To Year

List any professional licenses, registration or certification you possess (Include Drivers License, If applicable)

Clerical or Other Skills
(List all that are applicable to the position for which you are applying) Example: Typing, words per minute, PBX etc.

Proficient in the following Software:

Business machines and/or equipment you can operate:

Employment History Please provide a minimum of the most recent 10 Years employment history including any period of unemployment.
C U R R E N T	Length of Employment (From/To)	Company	Phone No.	Immediate Supervisor
	Salary $	Address		May we contact them? Yes No
	Job Title and Nature of Duties			Reason for leaving

1st P R E V I O S	Length of Employment (From/To)	Company	Phone No.	Immediate Supervisor
	Salary $	Address
	Job Title and Nature of Duties			Reason for leaving
Additional Employment History

Professional References (Other than Relatives) Give two references who have good knowledge of your work.
	Name and Position	Address (Include City/State)	Phone - Work/Home	Number of Years Know
1.
2.

Please Review and Click Agree Where Indicated.
In making application for employment.

I certify that the information in this application is true and complete for all practical purposes. It may be verified by the facility or any affiliate. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the facility or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.
I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable. If such an investigative report is made, I understand that I will receive notice that such report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.

I UNDERSTAND AND AGREE THAT ANY EMPLOYEE HANDBOOK WHICH I MAY RECEIVE WILL NOT CONSTITUTE AN EMPLOYMENT CONTRACT, BUT WILL BE MERELY A GRATUITOUS STATEMENT OF FACILITY POLICIES.
I understand that the facility reserves the right to require its employees to submit to blood tests or urinalyses for alcohol or drug screens, or to allow inspection of bags (including purses or briefcases) or parcels brought into or taken out of the facility. I understand that refusal to submit to a urinalysis, blood test or search, when requested to do so, may result in termination of my employment.
Compliance with this facility's Substance Abuse Policy is a condition of employment. This hospital requires that every newly hired employee be free of alcohol or drug abuse. Each offer of employment is contingent up successfully completing a urinalysis test/screen for alcohol and drugs in accordance with hospital policy. Continued employment is also contingent upon compliance with the hospital's Alcohol and Drug Abuse Policy.

I agree to immediately disclose to the Company any debarment suspension, exclusion or other event that makes me ineligible to participate in any Federal health care program, or receive a government contract.
I UNDERSTAND AND AGREE THAT IF I AM OFFERED EMPLOYMENT BY THE FACILITY, MY EMPLOYMENT WILL BE FOR NO DEFINITE TERM AND THAT EITHER I, OR THE FACILITY WILL HAVE THE RIGHT TO TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, I ALSO UNDERSTAND THAT THIS STATUS CAN ONLY BE ALTERED BY A WRITTEN CONTRACT OF EMPLOYMENT WHICH IS SPECIFIC AS TO ALL MATERIAL TERMS AND IS SIGNED BY ME AND THE ADMINISTRATOR OF THE FACILITY.
Release:
I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my licensure status and my licensure history.

I have read and understand these conditions of employment.