Nebraska Heart Institute, P.C. and Nebraska Heart Hospital, LLC are Equal Opportunity Employers. It is our policy not to discriminate against any applicant because of age, race, religion, color, sex, sexual orientation, disability, marital status or national origin and other categories protected by law.

Fields marked with a * are required.

Personal Information
Name
  * Last * First * MI
Present Address
  * Street * City * State * Zip

Email

* Primary Phone No. Alternate Phone No.
* Have you worked under another name? If so, list name(s)
 
* If hired, can you provide proof of your citizenship or other eligibility to be employed in the United States?
* Have you ever applied to, or worked for Nebraska Heart Institute or Nebraska Heart Hospital before?
If so, when? What location?
 
* Do you have any relatives currently working for either organization?
If yes, state name and relationship:
 
* Have you ever been convicted of a felony or misdemeanor?
If yes, please give details:
 
* Have you ever been discharged from any position?
If yes, please give details:
 
* Have you ever been excluded from participation in a federally funded program? (i.e. Medicare, Medicaid)
If yes, please give details:
 
If offered a position with our organization, are you willing to submit to a drug test?
General Information About Employment Desired
Available Positions








Salary Desired
Desired Status
If part-time or temporary, days of the week and hours you are available to work:
If hired, date you are available to begin work:
Referral Source: (i.e. newspaper, employee, internet, etc.)
If employee referral, please list employee's name:
Professional Licenses, Registrations And/Or Certifications
Profession: State Issued: License Number:
Has your professional license (in any state) ever been on probation, suspended, revoked or limited in any way?
If so, give reason:
Certification Number Registration Number
Other Special Skills And Professional Memberships
Please list any special office or technical skills you feel are important to your possible employment with us:
Please list any professional groups in which you hold membership:
Education Background
Highest Grade Completed:
Name and Location of College or Vocational Education Major or Specialty Did you Graduate Diploma or Degree Earned (If not graduated, how many credit hours have been earned?)
References
List three work references (please do not list relatives). Include name, phone number and working relationship.
1.
2.
3.
Employment Experience

List your present or most recent employer FIRST. Include U.S. Armed Forces experience. This information must be completed in full. Do NOT put "See Resume."

Employer: Supervisor:
Address & Phone Number:
Dates Employed: Job Title:
Major Responsibilities
Ending Salary: Reason for Leaving:
May we contact for reference? If no, why?
Employer: Supervisor:
Address & Phone Number:
Dates Employed: Job Title:
Major Responsibilities
Ending Salary: Reason for Leaving:
May we contact for reference? If no, why?
Employer: Supervisor:
Address & Phone Number:
Dates Employed: Job Title:
Major Responsibilities
Ending Salary: Reason for Leaving:
May we contact for reference? If no, why?
Employer: Supervisor:
Address & Phone Number:
Dates Employed: Job Title:
Major Responsibilities
Ending Salary: Reason for Leaving:
May we contact for reference? If no, why?
Employer: Supervisor:
Address & Phone Number:
Dates Employed: Job Title:
Major Responsibilities
Ending Salary: Reason for Leaving:
May we contact for reference? If no, why?
Optional, Attach Cover Letter and/or Resume
Cover Letter (optional)
Resume (optional)
Certification

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are complete, true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application.

I understand that any offer of employment is contingent upon successfully completing a background check which includes, but may not be limited to, verifying my eligibility to participate in federally funded programs, criminal background investigation and employment reference checking. I further understand that any false or incomplete statements shall be grounds for rejection of this application or termination of employment, regardless of the time elapsed before discovery.

I agree to submit to a post-offer drug test and realize that employment is contingent upon completing and passing a drug test.

* Nebraska Heart Hospital applicants only: I agree to submit to a post-offer physical examination and recognize employment is contingent upon successfully meeting physical requirements.

In consideration of my employment, I agree to conform to the rules and regulations of Nebraska Heart Institute and Nebraska Heart Hospital. If hired, my employment will be employment at will and may be terminated, with or without cause, at any time, at the option of Nebraska Heart Institute or Nebraska Heart Hospital or myself. No employee of either organization has the authority to make binding promises to the contrary.

If you agree to the terms set forth above, please type "I AGREE" in the space provided:

IMPORTANT! To complete this application, you must read the paragraphs above and fill in the following blanks with your full first and last name and today's date.

 
* Signature * Date  

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