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connecticut health facilities
Connecticut jobs
Thank you for your interest in Connecticut Health Facilities.
Please either submit the following form online or download and print this form and submit by mail or fax.

Connecticut Health Facilities
Application For Employment

The Suffield House
One Canal Road
Suffield, CT 06878
860-668-6111
Fax - 860-668-0061
Eagle Pointe
One Canal Road
Suffield, CT 06878
860-668-6111
Fax - 860-668-3711
CT Health of Greenwich
1188 King Street
Greenwich, CT 06831
203-531-8302
Fax - 203-531-8747
CT Health of Southport
930 Mill Hill Terrace
Southport, CT 06890
203-259-7894
Fax - 203-259-4521
Connecticut Health Facilities is an equal opportunity employer, dedicated to a policy of nondiscrimination in employment on any basis prohibited by law. Connecticut Health Facilities considers applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation or any other legally protected status.
PERSONAL INFORMATION
Last Name:
First Name:
Middle:
Street Address:
City:
State:
Zip:

Social Security #:
Home Phone:
Work Phone:
Cell Phone:
Email Address :
EMPLOYMENT DESIRED
Position(s) applied for:
Which facility are you applying for a position of employment:
Rate/ Salary Desired:
On whate date would you be available to work:
Nurses:
CT Licence Number:
Nurses Aides:
Certified:
Certification Number :
Have you ever been dismissed, involuntarily terminated or forced to resign from employment?
If yes, please explain:
EDUCATION AND TRAINING
Type of school
Name & Address
Years Completed
Course of Study
 Diploma/ Degree
Elementary and Middle School
High School
College
Business / Trade
Describe any specialized training, licenses, certifications, and skills:
Has any license or certification you have held been surrendered, suspended or revoked for any reason? If so,
please explain:
EMPLOYMENT EXPERIENCE
Provide your complete employment history for the past 15 years. Do not omit any jobs. Include any job-related military service assignments and volunteer activities.
Employer: From: To:
Address: Hourly Rate/ Salary:
Telephone Number(s) Job Title
Duties and Accomplishments:
Supervisor Name and Title:
Reason for leaving
Employer: From: To:
Address: Hourly Rate/ Salary:
Telephone Number(s) Job Title
Duties and Accomplishments:
Supervisor Name and Title:
Reason for leaving
Employer: From: To:
Address: Hourly Rate/ Salary:
Telephone Number(s) Job Title
Duties and Accomplishments:
Supervisor Name and Title:
Reason for leaving
Employer: From: To:
Address: Hourly Rate/ Salary:
Telephone Number(s) Job Title
Duties and Accomplishments:
Supervisor Name and Title:
Reason for leaving
REFERENCES
Give the names of three persons not related to you whom you have known at least one year.
Name
Address
Home Phone
Business Phone
If you have worked under a different name at any of the job (s) listed, please indicate the different name and when used:
SKILLS AND EXPERIENCE FOR STAFF AND SECRETARIAL POSITIONS ONLY
Years of secretarial experience: Typing Speed:
Knowledge of Word Processing Programs:
Additional comments which you feel would be important:
NOTICE OF BACKGROUND CHECK AND FAIR CREDIT REPORTING ACT DISCLOSURE

As part of the interview process, Connecticut Health Facilities may conduct a background check. If you are hired, Connecticut Health Facilities may also conduct a background check in deciding whether to continue your employment and when making other employment-related decisions directly affecting you. As part of the background check, Connecticut Health Facilities may obtain a “consumer report” from a “consumer reporting agency.” These terms are defined in the Fair Credit Reporting Act (“FCRA”), which applies to you. A consumer report includes information regarding such issues as your credit standing, criminal record, motor vehicle record, character and reputation. If Connecticut Health Facilities obtains a “consumer report” about you, and considers any information in the “consumer report” when making an employment-related decision that directly and adversely affects you, you will be provided with a copy of the report before the decision is finalized. You may also contact the Federal Trade Commission in Washington, D.C., about your rights under the FCRA as a consumer with regard to “consumer reports” and the “consumer reporting agencies” that prepare these reports. Your signature below authorizes Connecticut Health Facilities to obtain consumer reports regarding you from consumer reporting agencies in connection with your application and during the course of your employment.

To perform the background check, please provide the following information:
Social Security No. Date of Birth
Drivers License No. State
Name:
Former Name:
AUTHORIZATION TO COLLECT BACKGROUND INFORMATION

I have applied for employment with Connecticut Health Facilities. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I authorize representatives of Connecticut Health Facilities to obtain pertinent information from my previous employers, references, and other persons with knowledge of my work history and background, financial history, education, regulatory or police records, driving records, licensing status or professional designation, and character or reputation, and to consider the information provided by the background check when making decisions regarding my employment at Connecticut Health Facilities.


I authorize all previous employers, references or other persons having knowledge of my record or myself to release such information to, and hereby release all persons from liability for any damage that may result from furnishing such information to Connecticut Health Facilities.


A photocopy of this authorization may be accepted in lieu of the original.
Name:
Date: