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Employee Voluntary Invitation to Self-Identify Voluntary Self-Identification of Disability
Please select the position you are interested in applying for:
ACH General ApplicationASSISTANT SUPERVISOR/CORE LABCERTIFIED NURSING ASSISTANTS/PART TIME & FULL TIME/ALL SHIFTS/FINGER LAKES CENTER FOR LIVINGCT TECHNOLOGIST/FULL TIME EVENINGS/12 HOUR SHIFTSDIETARY POSITIONS/PART TIMEDIRECTOR OF EMERGENCY ROOMER RN Position AvailableFamily Nurse PractitionerFloat RN Position AvailableFULL TIME RN CASE MANAGERHOUSEKEEPING ATTENDANTS/FULL TIME & PART TIMELICENSED PRACTICAL NURSES/PART TIME & FULL TIME/FINGER LAKES CENTER FOR LIVINGMANAGER OF CENTRAL STERILE SERVICESMANAGER OF PATIENT FINANCIAL SERIVCESMed/Surg Nursing Positions AvailableMedical Office LPNNP/PA - NephrologyNurse Midwife - Auburn OB/GYNNURSING SUPERVISOR/FULL TIME & PART TIME/FINGER LAKES CENTER FOR LIVINGOB/GYN Registered NursesOPERATING ROOM TECHNICIANPart time Respiratory TherapistPatient Safety Companion/Sitter (Per diem)Per Diem MDS Coordinator - Finger Lakes Center For LivingRadiologic Technologist/Interventional Radiology/Per diemRespiratory Therapist Positions, Full time & Part time - Flexible ShiftsRN Case Manager - Per DiemRN CLINICAL LEADER/CRITICAL CARE & TELEMETRYSECURITY GUARD/PART TIME/NIGHTSTelemetry Nursing Positions AvailableULTRASONOGRAPHER/FULL TIME/ 4P -12AVISITOR SCREENER/PER DIEM/TEMPORARY
Disclaimer: Positions listed below may not be available at the time of application, however, all applicants will be placed into a pool and considered when job availability opens up.
First Name (required)
Last Name (required)
Home Phone (required)
E-Mail Address (required)
How did you learn of this position? Employee ReferralWalk InMonster.comCareer BuilderJob FairTemp AgencyCollege RelationsOpen HouseExternshipAdCommunity or Other AgencyOther
If ad, friend, relative, job fair or other, specify
Date Available for Work (required)
Type of Employment Desired No preferenceFull-timePart-timePRNWeekendOvernightTemporarySummerPer Diem
Are you willing to work weekends? (required) YesNo
Are you willing to work holidays? (required) YesNo
Are you legally authorized to work in the US? (required) YesNo
Are you 18 years of age or older? (required) YesNo
Have you applied for employment with our organization within the past two years? (required) YesNo
Do you have any employment commitments with any other employer, including any form of self-employment or contract work, which you expect to keep even if you are hired by our company? (required) YesNo
Have you ever been known by a different name? (required) YesNo
Can you perform the essential functions of the job for which you are applying with or without reasonable accommodations? (required) YesNo
Enter Name & Location of all High Schools, Vocational Schools, Business Schools, Colleges, and Related Military Courses attended.
# of Years of High School Completed
# of Years of College Completed
Other Trade, Business, Night or Correspondence School
Typing Words Per Minute
Medical Terminology Knowledge YesNo
Medical Coding YesNo
List Computer Program Knowledge
Are there any other special experiences or skills you feel would especially qualify you for the position?
Branch of Service
Rank at Discharge
Date of Final Discharge
Describe your duties & any special training which may be related to the position(s) for which you are applying
Name/Title of Immediate Supervisor
Describe your work/responsibilities
Reason for Leaving
May we contact the employer? ---YesNo
If you wish, you can upload a resume/cover letter below.
Gender MaleFemaleOtherPrefer Not to Say
Veteran Status YesNoPrefer Not to Say
Have you been a resident of New York for the past two consecutive years? (required) YesNo
Have you ever been convicted in any state of the United States of a felony or misdemeanor? (required) YesNo
Are there any criminal charges pending against you anywhere? (required) YesNo
Have you ever been convicted of an offense (misdemeanor or felony) other than a minor traffic violation? (Driving under the influence [DUI] and Driving while intoxicated [DWI] convictions are not minor and must be reported.) YesNo
Have you ever been found guilty of a criminal offense? YesNo
Have you ever been imprisoned or jailed in a criminal proceeding? YesNo
A "yes" to any questions above does not automatically keep you from being hired. If you answered "yes" to any questions you must fully explain.
Your omission or falsification of any criminal history, or any disclosure required by this form, is a cause for dismissal from employment or consideration for employment.
Examples of a criminal offense: Assault/battery, auto theft, disorderly conduct, domestic violence, DUI/DWI, fraud ( welfare/food stamps) loitering, prostitution/solicitation, robbery, shoplifting, theft (grand/petty), trespassing, worthless checks. Note: This is not a complete list and is intended to provide examples only. You must list all convictions including juvenile incidents and those in which adjudication was withheld and/or records were sealed/expunged.
I verify that this information is true, and that I have not been convicted of any crime that would disqualify me from the position(s) for which I am applying. I hereby authorize company to request, obtain and examine any and all records that may relate to my arrest, conviction and/or imprisonment at any time for any felony or misdemeanor and I expressly release and hold harmless any party providing the aforementioned criminal information requested by company. (required)