Click the Upload Resume to use your resume to pre-fill this application form.
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Is additional information relative to a change of name, use of an
assumed name or nickname necessary to enable a check on your
Other Names Used:
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?
Hudson River Healthcare Careers Website
Hudson valley Help Wanted
Monster - Authenticated
Other (Please Specify)
Other (Specify Source):
If you were referred to us by a current employee, please provide their full name.
Format: M/D/YY *
Desired Employment Type:
If Part Time, state days and hours desired.
Are you legally authorized to work in the United States?
Authorized to Work:
Will you now or in the future require sponsorship for
Employment Visa Status (e.g. H-1B Visa Status)?
I am authorized to work in this country for any employer
I am authorized to work in this country for my present employer only
I require sponsorship to work in this country
My status to work in this country is unknown
Have you previously applied at or worked for Hudson River HealthCare, Inc. or an affiliate?
If yes, please provide dates of employment, location, and title.
Previous Employee Details:
Are you under the age of 18?
If yes, do you have working papers?
Were you employed while you were in school?
If yes, how many hours did you work each week?
Employment in School:
# of Hours per Week:
Are you currently employed? If yes, may we contact your current employer?
Contact Current Employer:
Were you ever discharged or asked to resign from any position? If yes, please explain.
Discharged/Asked to Resign:
Note: This question does not apply to convictions which have been expunged, sealed, pardoned, or otherwise exonerated or
eradicated, or relate to a youthful offender conviction or violation. (A conviction record will not necessarily be a bar to employment.
A conviction which is substantially related to the functions or qualifications of the position(s) for which you are applying may be taken
into consideration.) Have you ever been convicted of a crime? If “Yes,” please describe fully the criminal conviction(s), listing the nature and date of the offense(s) and
your rehabilitation since the conviction(s).
Employment History - LIST YOUR WORK EXPERIENCE FOR THE LAST TEN (10) YEARS. START WITH YOUR PRESENT OR MOST RECENT EMPLOYER AND THEN CONTINUE LISTING, IN CHRONOLOGICAL ORDER, ALL EMPLOYMENT HELD FOR THE LAST TEN (10) YEARS.:
Additional Skills & Qualifications
List any skills, experience, or activities which will help you perform the job for which you are applying (please do not
provide any information that would directly or indirectly indicate your sex, race, color, religion, age, national origin,
citizenship, disability or any other characteristic protected by Federal, State or Local law):
References - PLEASE FURNISH THREE REFERENCES THAT ARE NEITHER RELATIVES NOR FORMER EMPLOYERS:
Your resume can be uploaded in any of the following formats: DOC, DOCX, RTF, PDF, TXT, HTML.
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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.
I HAVE READ AND FULLY UNDERSTAND THE QUESTIONS ASKED IN THIS APPLICATION. I UNDERSTAND THAT
NEITHER THIS APPLICATION NOR ANY COMMUNICATION BY A MANAGEMENT REPRESENTATIVE IS INTENDED TO
CREATE A CONTRACT OF EMPLOYMENT FOR ANY PERIOD. IF HIRED, I UNDERSTAND THAT MY EMPLOYMENT MAY
BE TERMINATED AT MY OPTION OR AT ANY TIME BY THE COMPANY WITH OR WITHOUT CAUSE OR NOTICE.
I GIVE HUDSON RIVER HEALTHCARE INC., ITS AFFILIATES, AND PARENT COMPANY PERMISSION TO VERIFY ALL
INFORMATION PROVIDED ON THE APPLICATION OR IN THE INTERVIEW(S), INCLUDING THE INQUIRY CONCERNING
CRIMINAL CONVICTION(S), AS WELL AS CONTACTING ANY AND ALL OR ANY OF MY PREVIOUS EMPLOYERS AND
REFERENCES AND AUTHORIZE THEM TO PROVIDE ALL INFORMATION REQUESTED OF THEM BY THE COMPANY. I
RELEASE THE COMPANY, MY FORMER EMPLOYERS AND OTHERS PROVIDING INFORMATION FROM ALL LIABILITY
WHATSOEVER RESULTING FROM THE DISCLOSURE OF SUCH INFORMATION.
I CERTIFY THAT I HAVE PROVIDED TRUTHFUL AND COMPLETE RESPONSES TO ALL INQUIRIES IN THE APPLICATION
OR INTERVIEWS AND UNDERSTAND THAT THE DISCOVERY OF ANY FALSE, MISLEADING INFORMATION AND OR
THE FAILURE TO PROVIDE INFORMATION WILL RESULT IN THE IMMEDIATE REJECTION OF MY APPLICATION OR, IF
I AM HIRED, WILL RESULT IN MY IMMEDIATE TERMINATION FROM EMPLOYMENT. I FURTHER UNDERSTAND THAT
AFTER A CONDITIONAL OFFER OF EMPLOYMENT, I MAY BE ASKED TO SUBMIT TO PRE-EMPLOYMENT DRUG TEST
AS A CONDITION OF EMPLOYMENT, AND ANY OFFER OF EMPLOYMENT IS CONTINGENT UPON MY RECEIPT OF A
NEGATIVE DRUG TEST RESULT AND SATISFACTORY REFERENCES.
THIS APPLICATION WILL REMAIN ACTIVE FOR SIX MONTHS FROM THE DATE COMPLETED.
Format: M/D/YY *
Voluntary Equal Opportunity Questionnaire
As an equal opportunity employer, we hire without consideration to race, religion, creed, color, national origin, age, gender, sexual orientation, marital status, veteran status or disability. We invite you to complete the optional self-identification fields below used for compliance with government regulations and record-keeping guidelines.
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
Other Protected Veterans
Armed Forces Service Medal Veterans
Recently Separated Veterans
Choose Not to Disclose