724-443-0700

Allegheny, Beaver and Butler Counties

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St. Barnabas Employment Application

Please complete the below application form.

Position applying for:

First name:

Middle initial:

Last name:

Address:

City:

State:

Zip:

Email:

Phone:

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Length of residence in Pennsylvania (may require FBI fingerprint check):
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Older than 18: *

If under 18, what is your date of birth:

If under 18, can you provide a work permit:

Job Type

Are you currently employed: *

Date available to start employment:
*

Are you interested in: *

If temporary, please explain:

Are you willing to work weekends:

Are you willing to work over-time:

Explain any hours / days you are unavailable to work:

Why are you interested in working for St. Barnabas Health System:
*

How did you learn about employment possibilities with St. Barnabas: *

If "Employee Referral" or "Other" please specify:

Additional Information

Are you a smoker: *

Have you previously been employed by St. Barnabas Health System: *

If yes, specify when and what department:

Have you previously worked in a long-term care or other health care facility: *

If yes, please explain:

How many days were you absent from work in 2018: *

How many days were you absent from work in 2017: *

Have you been discharged from previous employment besides layoff: *

If yes, please explain:

Have you been convicted of a crime: *

If yes, please explain:

Have you ever been barred or sanctioned by Medicaid or Medicare: *

If yes, please explain:

Do you use illegal drugs: *

Education

Highest grade completed: *

High School:

College:

Other:

Special Training:

Military Service

Have you served in the U.S. Armed Forces: *

If not applicable leave the related fields below blank.

Present status:

Military branch:

Enlistment date:

Discharge date:

Discharge type:

Final rank:

Classification:

Work Experience

Begin with your most recent or current job. Volunteer activities may be included. Exclude organizations which indicate race, color, religion, gender, national origin, sexual orientation, disability or other protected status.

Employer #1

Name:
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Address:
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Phone:
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Supervisor:
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Position:
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Responsibilities / Duties:
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Dates employed:
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Hourly rate / salary:

Reason for leaving:
*

Employer #3

Name:

Address:

Phone:

Supervisor:

Position:

Responsibilities / Duties:

Dates employed:

Hourly rate / salary:

Reason for leaving:

Employer #2

Name:

Address:

Phone:

Supervisor:

Position:

Responsibilities / Duties:

Dates employed:

Hourly rate / salary:

Reason for leaving:

Employer #4

Name:

Address:

Phone:

Supervisor:

Position:

Responsibilities / Duties:

Dates employed:

Hourly rate / salary:

Reason for leaving:

Can these employers be contacted: *

If no, please explain:


Personal References

List three references, other than relatives or former employers.

Reference #1
Name:
*
Occupation / Title:
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Address:
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Phone:
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Amount of time known:
*

Reference #3
Name:
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Occupation / Title:
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Address:
*
Phone:
*
Amount of time known:
*

Reference #2
Name:
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Occupation / Title:
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Address:
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Phone:
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Amount of time known:
*

ST. BARNABAS HEALTH SYSTEM, INC. IS AN EQUAL OPPORTUNITY EMPLOYER AND DOES NOT DISCRIMINATE BECAUSE OF RACE, RELIGION, COLOR, AGE, GENDER, NATIONAL ORIGIN, MARITAL STATUS, DISABILITY OR HANDICAP, VETERAN STATUS, SEXUAL ORIENTATION, OR ANY OTHER STATUS PROTECTED BY LAW. NO QUESTION ON THIS APPLICATION IS INTENDED TO SECURE INFORMATION TO BE USED FOR SUCH DISCRIMINATION. THIS IS NEITHER AN EMPLOYMENT CONTRACT NOR A GUARANTEE OF EMPLOYMENT. YOUR COMPLETED APPLICATION WILL BE MAINTAINED IN OUR ACTIVE FILES FOR THIRTY (30) DAYS FROM THE DATE OF APPLICATION. YOU MAY SUBMIT A NEW APPLICATION OR UPDATE THIS APPLICATION AT ANY TIME.

1. If you require any special reasonable accommodation completing this application, interviewing, completing any pre-employment testing, or otherwise participation in the employee selection process, please advise us.

2. You will be required to pass a drug and or alcohol screening test as a condition of employment.

3. By signing below, you understand that all statements made herein are subject to verification by St. Barnabas Health System Inc. and you hereby release St. Barnabas Health System, its related entities and employees from all liability associated with these statements and how they are utilized in the employment process.

4. I understand that an investigative consumer report is a report in which information concerning my character, general reputation, personal characteristics, or mode of living, is obtained through personal interviews with neighbors, friends, or associates with whom I am acquainted. By signing below, I am authorizing the St. Barnabas Health System, Inc. to obtain a consumer or investigative consumer report on me as part of the St. Barnabas Health Systems, Inc. background screening process.

5. I specifically hereby authorize in writing St. Barnabas Health System Inc. and or its assigns to conduct a Credit Check as defined by the federal Fair Credit Reporting Act (FCRA), conduct a criminal background check, and when not a resident of Pennsylvania for at least two years, conduct an FBI fingerprint check. Your authorization below meets the standards to allowing St. Barnabas Health System Inc. and or its assigns to contact a consumer reporting agency who may provide information about you.

Signature:

Date:

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* Indicates mandatory information is required to submit.

Contact

For general information about
St. Barnabas Health System,
call (724) 443-0700.

St. Barnabas Health System
5850 Meridian Road
Gibsonia, PA 15044

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For job inquiries
please call (724) 444-JOBS or
email St. Barnabas Human Resources Department.

St. Barnabas Human Resources Department
6005 Valencia Road
Gibsonia, PA 15044

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