Dear Applicant:

Thank you for your interest in employment with Chilton Hospital.

You may submit the application electronically by typing directly into the form or download the
application and manually complete, sign and submit.
Please be advised that all offers of employment are contingent upon successful completion of our
clearance process. This process includes a background check and pre-employment physical.
Background Check: Please be accurate and thorough on your employment application
since all information will be verified through the background check process. Providing
false information or omitting requested information may result in the withdrawal of an
employment offer.
Pre-employment physical: We do test for illegal drugs. If you use illegal drugs, please do
not apply.
When you return the completed job application, Human Resources will review it. If we have a
suitable position available, we will contact you either by phone or e-mail. Because Chilton
receives numerous employment applications each day, we are unable to respond to each
applicant.
Once again, thank you for your interest in employment with Chilton Hospital.

Human Resources
Email address: recruiter@chiltonhealth.org
Mailing address: 97 West Parkway, Pompton Plains, NJ 07444
Human Resources office location:
Chilton Health Network, 242 West Parkway, Pompton Plains, NJ 07444
Telephone 973.831.5050
Fax 973.831.5516

For a listing of current opportunities visit

www.chiltonhealth.org, click Job Opportunities.
Equal Opportunity Employer

Employment
Application

97 West Parkway Pompton Plains, NJ 07444

Human Resources: 973-831-5050
Fax: 973-831-5516 www.chiltonhealth.org

----Please print all information

Employment Desired
Registered Nurse
March 21, 2012
Positions you are applying for: 1. __________________________________________________________
Date ________________
2. __________________________________________________________

March 25, 2012

Date available to start: ____________________________
Are you employed now?

Available for:

Full Time

Part Time

Shift Preference (1st, 2nd, 3rd choice)

Days

On Call/Per Diem
Evenings

Yes

No

Other

Nights

40
Hours available to work ___________

Will you work alternate weekends/holidays? Yes

Will you work weekends/holidays? Yes No
You are not required to indicate the need for time off due to religious practices.

No

After you have completed the remainder of the job application, please obtain a job description for the position you seek and
answer the following question: Can you perform the essential job functions with or without an accommodation? Yes No

Personal Information
Cansino
Althea Louisse
A.
Name_______________________________________________________________________________________________________
Last

First

Middle Initial

815 Albany Ave.

Brooklyn
NY
11203
Present address ______________________________________________________________________________________________
Street

City

State

Zip

teasis_1027@yahoo.com
Email address ________________________________________________________________________________________________
347
240-0097
always
Home phone no. (______)
________________________________
When available at this number ____________________________
Area Code

Cell phone no.

(______)_________________________________
Area Code

Work phone no. (______)_________________________________ May we contact you at work?

Area Code

Are you 18 years of age or in possession of a valid work permit?

Yes

Yes

No

No

Are you either a United States Citizen or an alien who has the legal right to work in the job you are applying for?
(All employees are required to complete form I-9 within three business days of the date of hire).
Have you ever been employed by Chilton Hospital?

No

Yes

No

Yes If so, when? From ___________ To ___________

Positions: _________________________________________________________________________________________________
Have you applied for employment at Chilton in the past three years?
Have you ever been a Chilton Volunteer?

No

Yes

No

Yes If so, when? From ___________ To ___________

If related to Chilton employee, please provide: _____________________________________________________________________

Name

Department

Relation

1. Have you ever pled guilty, no contest (no lo contender ) or been convicted of a crime which has not been expunged, annulled,
sealed, pardoned, or statutorily eradicated by the Court? [Before you answer, please note that a conviction or plea of guilty will not
necessarily be a bar to employment.] Yes No
2. If yes, please describe the nature of the crime, the date of the conviction and completion of any sentence and any subsequent
rehabilitation. ____________________________________________________________________________________________
_______________________________________________________________________________________________________
EQUAL OPPORTUNITY EMPLOYER
Chilton Hospital (Chilton) is an equal opportunity employer that does not discriminate in hiring and employment on the basis of race, creed, religion, color, national origin,
ancestry, age, sex, affectional or sexual orientation, gender identify or expression, marital status (including Civil Unions), familial status, domestic partnership, atypical
hereditary cellular or blood trait, disability (including AIDS and HIV infection), genetic information, liability for service in the United States armed forces or any other
characteristic protected under applicable federal, state or local laws. Chilton will make a reasonable accommodation to known physical or mental limitations of a qualified
applicant or employee with a disability unless the accommodation would impose an undue hardship on the operation of the hospital. No questions on this application are asked
for any unlawful purpose.

Please print all information

How were you referred to us?

Own initiative ______________________________________

Employee referral____________________________________

Advertisement/publication_____________________________

Job Fair ___________________________________________

Chilton website

Other _____________________________________________

please specify

Other website ______________________

please specify

please specify

please specify
please specify

Education and Training

Name and Location
(City, State)

School

Saint Francis School Manila, Philippines

High School (last

attended) or G.E.D.

Business/
Technical School

Check Highest
Year Completed

Course of
study

Did you
graduate?
Check one

Degree or
certificate

1 2 3 4

Yes No

HS Diploma

1 2 3 4

College/University

Makati Medical Center- College of Nursing Makati, Philippines

1 2 3 4

College/University

Graduate School

Do you possess any other skills which you feel would contribute
toward your ability to perform the job for which you are applying?
(Exclude any information that may reveal your membership in a
legally protected classification.)___________________________
Have you ever worked or been educated under another name?

Yes No

Yes No

1 2 3 4

Yes No

1 2 3 4

Yes No

BSN

Word

Access

Excel

35
Typing = ________
wpm

PowerPoint

Yes No

Name:___________________________________________ School/Employer:_____________________________________________
please specify

Licensure
List professional/technical licenses you have acquired. Indicate name on license if different from name on front of application.
Type
State
License/Certificate #
Exp. Date
RN
NY
652684
12/31/2014
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Have you held a license in a different state?

Yes

No (Please Specify) State ____________________________________

Have you ever had your professional license/certification denied, suspended, revoked or withheld by any licensing body in any state
for any reason?

Yes

No

If so, please explain: ________________________________________________________________________________________

________________________________________________________________________________________________________
To your knowledge have you ever been the subject of any investigation, inquiry, or administrative proceeding by any
licensing/certification body or other governmental agency regarding your professional conduct?

Yes

No

If so, please describe the circumstances and how the matter was resolved, including any fines, penalties or other sanctions
assessed.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Have you ever had or are you aware of any threatened or pending professional liability claims made against you and/or a prior
employer related to your conduct and performance at work?

Yes

No

Please print all information

Employment History Please complete all information. Do not write See Resume. Begin with your last or present
employer. Do not omit any employment history. If you have past military experience, please
include it in this section in the proper date order. After an offer of employment is made and
accepted, the offer will be contingent upon, among other things, acceptable references.

Title _______________________________________________________ Company Name _____________________________________________

Address _______________________________________________________________________________________________________________
Street

City

Phone # ______________________________________________

Full Time

State

Part Time

Zip Code

Per Diem

Shift: _________________

Supervisors name __________________________________________________ Title: _______________________________________________

Dates employed from: _____________________month/yr

to: ________________________ month/yr

Salary: ___________________________

Description of work: ______________________________________________________________________________________________________

Reason for leaving: __________________________________________________________________ (Please check)

Voluntary

Involuntary

Title _______________________________________________________ Company Name _____________________________________________

Address _______________________________________________________________________________________________________________
Street

City

Phone # ______________________________________________

Full Time

State

Part Time

Zip Code

Per Diem

Shift: _________________

Supervisors name __________________________________________________ Title: _______________________________________________

Dates employed from: _____________________month/yr

to: ________________________ month/yr

Salary: ___________________________

Description of work: ______________________________________________________________________________________________________

Reason for leaving: __________________________________________________________________ (Please check)

Voluntary

Involuntary

Title _______________________________________________________ Company Name _____________________________________________

Address _______________________________________________________________________________________________________________
Street

City

Phone # ______________________________________________

Full Time

State

Part Time

Zip Code

Per Diem

Shift: _________________

Supervisors name __________________________________________________ Title: _______________________________________________

Dates employed from: _____________________month/yr

to: ________________________ month/yr

Salary: ___________________________

Description of work: ______________________________________________________________________________________________________

Reason for leaving: __________________________________________________________________ (Please check)

Voluntary

Involuntary

Title _______________________________________________________ Company Name _____________________________________________

Address _______________________________________________________________________________________________________________
Street

City

Phone # ______________________________________________

Full Time

State

Part Time

Zip Code

Per Diem

Shift: _________________

Supervisors name __________________________________________________ Title: _______________________________________________

Dates employed from: _____________________month/yr

to: ________________________ month/yr

Salary: ___________________________

Description of work: ______________________________________________________________________________________________________

Reason for leaving: __________________________________________________________________ (Please check)

Voluntary

Involuntary

97 West Parkway Pompton Plains, NJ 07444

Human Resources: 973-831-5050
Fax: 973-831-5516 www.chiltonhealth.org

APPLICANTS AUTHORIZATION READ CAREFULLY

I hereby affirm that the information contained in this application (and accompanying documents, if any) is true and complete to the best
of my knowledge. I also agree that any misstatement, falsified information, or omission deemed significant by Chilton Hospital may
disqualify me from further consideration for employment and/or may be considered justification for dismissal if discovered after an offer
of employment has been extended.
I further affirm that I am not currently excluded from participating in any Federal or State Health Care Program and I am not included in
the Department of Health and Human Services List of Excluded Individuals/Entities. I understand that after a job offer is extended, but
prior to beginning work and then periodically thereafter as a condition of employment, Chilton Hospital will verify that I am not included
in the Department of Health and Human Services List of Excluded Individuals/Entities. If I receive notification that I have been excluded
I will notify Chilton Hospital immediately.
I understand that nothing in this application or any other Chilton Hospital document, or an acceptance of employment, creates or
constitutes an employment contract between Chilton Hospital and me, and that should I be hired, my employment would be at will,
which means that it would be for no fixed duration and could be terminated by me or Chilton Hospital at any time with or without notice
or cause. I understand that no oral or written statement to the contrary shall change this relationship, or should be relied upon by me.
If hired, as a condition of my employment, I agree to conform to the rules and regulations of Chilton Hospital. I understand that after a job
offer is extended, but prior to beginning work, I will be required to undergo a physical examination, which may include a drug and alcohol
test and which is in accordance with the requirements of the New Jersey State Department of Health, to verify my fitness to work.
I authorize all persons, schools, companies, corporations and organizations named in this application (and accompanying documents if
any), law enforcement agencies, and credit bureaus to release any information concerning my background, and I hereby release them
and Chilton Hospital from any and all claims of liability in law and in equity that may arise out of obtaining such information.
I understand that my employment is contingent upon my results of a consumer report that Chilton Hospital may obtain as part of its
employment background investigation.
By typing my name below and clicking on the I acknowledge and agree box below, I acknowledge and agree to all of the following:
That I have read, understood and agree to the foregoing;
That I will proceed with the application process through electronic means;
That my electronic signature is the equivalent of a manual signature and that the Hospital may rely on it as such;
That it is my obligation to immediately advise the Hospital of any change in my address/contact information;
That it is my obligation to immediately advise the Hospital in the event that I withdraw my consent to use electronic means for the
application process;
That the individual completing this application is the individual whose name is typed below.

I acknowledge and agree. (If you do not check this box, your application will not be considered.)

March 20, 2012

___________________________________
Date

althea louisse aducayen cansino

Digitally signed by althea louisse aducayen cansino

DN: cn=althea louisse aducayen cansino, o, ou,
email=teasis_1027@yahoo.com, c=US
Date: 2012.03.20 23:24:38 -04'00'

________________________________________________________________
Applicants signature

THIS APPLICATION WILL BE CONSIDERED FOR ONE YEAR FROM THE DATE IT IS SUBMITTED. SHOULD YOU WISH TO BE
CONSIDERED FOR EMPLOYMENT AFTER THAT DATE, YOU MUST SUBMIT A NEW APPLICATION.

FOR INTERNAL USE ONLY:

Start Date____________________
Category:

Title ________________________________
Full Time Regular
Part Time Regular
Part Time Other
Per Diem

Dept.____________ Dept. # _______________

On Call
Full Time Temporary
Part Time Temporary

Shift: _______________ Hours:_______________ Grade: _______________ FTE: ______________ Hourly rate: ______________
Requisition # __________________ Sign on Bonus __________________________________________________________________
Position # ___________________________________________________________________________________________________
HR Authorization: ____________________________________________ Date : ___________________________________________
CH Graphic Arts
196-004 R1211