APPLICATION FOR EMPLOYMENT Thank you for your interest in Robert Wood Johnson University Hospital at Rahway. We are an equal opportunity employer dedicated to a policy of non-discrimination on the basis of race, color, religion, gender, national origin, marital status, age, disability, sexual preference, military status and/or obligation or any other characteristics that are protected by applicable law. All offers of employment are contingent on the satisfactory completion of a pre-employment physical that includes a substance abuse screening.

In order to make the best possible match between your skills and experience and our requirements, we need a clear understanding of your background. You must fully complete this Application for Employment. All questions must be answered even if a resume is attached. Your resume is a supplement to the application not a replacement. INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED. The completed application form will be actively considered for 90 days. If you wish to be considered after that time, you must complete a new Application for Employment. If you are hired, proof of your eligibility to work in the United States must be provided within 3 days as specified by law.

Personal Information:   *Indicates areas that must be filled out. Name* Today's Date Street Address* The best time to reach me is: via the number(s) I have checked below: City* State* Zip* Home: Cell: Work: Pager: E-mail address:* Are you 18 years of age or older? Yes No Have you ever been employed by RWJUH at Rahway or Rahway Hospital? Yes No If Yes, when? Dates: From: to Position: Department: Name of last supervisor: Are you legally eligible to work in the USA? Yes No Do you have a valid Drivers’ License? Yes No Drivers’ License No.: To be completed only if relevant to the position for which the applicant is applying. Do you have any relatives by blood or marriage, or members of the same household who work for RWJUH at Rahway? Yes     No Name(s): Have you ever been convicted of a crime that was not/has not been annulled or sealed by a Court? Yes     No If Yes, please explain: A conviction will not necessarily disqualify an applicant from the job applied for.

Employment Desired: Position you are applying for: How were you referred to us? Advertisement/Publication Website listing Own initiative Former employee   Employment agency Employee referral Business acquaintance Other Date available to start: Salary desired: Available for: Full-time    Day shift        Night shift   Per Diem Part-time   Evening shift   Weekend    Temp Name: Will you be able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodations Yes No

Employment History List your complete employment history starting with your present position and working backwards. Include all military assignments and periods of unemployment (identify unemployment periods as "unemployed” and give specific dates.) Do not leave time gaps. Use additional pages if necessary to provide all requested information. Company Name May we contact? Yes No Employed (month/year) From:     To: Street address Salary Start:  Last: City State Zip (Area code) Telephone Job Title Name and title of Supervisor (Area code) Telephone Duties and responsibilities (describe briefly) Reason for Leaving: Company Name May we contact? Yes No Employed (month/year) From:     To: Street address Salary Start:  Last: City State Zip (Area code) Telephone Job Title Name and title of Supervisor (Area code) Telephone Duties and responsibilities (describe briefly) Reason for Leaving: Company Name May we contact? Yes No Employed (month/year) From:     To: Street address Salary Start:  Last: City State Zip (Area code) Telephone Job Title Name and title of Supervisor (Area code) Telephone Duties and responsibilities (describe briefly) Reason for Leaving:

Education School Name and Location (City, State) Circle Highest Year Completed Course of Study Did you graduate? Degree or Certificate High School (last attended) or G.E.D.   1    2    3    4 Yes No Business/Technical School   1    2    3    4 Yes No College/University or Technical School   1    2    3    4 Yes No College/University or Technical School   1    2    3    4 Yes No Graduate School   1    2    3    4 Yes No

Have you ever worked or been educated under another name? Yes No Name:    Nickname:

Training List training, non-degree courses, certifications; professional/trade association memberships; and any volunteer work that you consider relevant to your ability to perform the job you are applying for.

Computer and Specialized Skills Check items for which you have substantial knowledge. Testing may be administered Word Excel PowerPoint Access Internet/e-mail Typing = wpm 10-key adding machine Calculator ICD-9 CRT E/M encoder SoftMed Automated A/P system Other databases Other Name: Professional and Technical Licenses or Certifications Type: Number: State Issued: Date Issued: Expiration Date:

References List three references familiar with your recent work that we may contact. Do not list family members or relatives. “Professional relationship” identifies your relationship to that individual; i.e.: manager, co-worker, customer, etc. Name (Area code) Telephone Company Position/Title Professional relationship Name (Area code) Telephone Company Position/Title Professional relationship Name (Area code) Telephone Company Position/Title Professional relationship

Applicant's Authorization and Acknowledgement I hereby certify that the information provided on this application (and any accompanying/ required documents/information provided in connection with my application) is true, complete, and correct to the best of my knowledge. I understand that any misrepresentation or omission of facts will result in denial of employment or immediate termination of employment. I understand that submission of an application does not guarantee employment. I also understand that nothing in this employment application or in the interview process, is intended to create an employment contract between myself and Robert Wood Johnson University Hospital at Rahway (RWJUH at Rahway) for either employment or for the provision of benefits. I understand that RWJUH at Rahway is an Employer-at-Will and that if hired, it is not for any specified duration and our employment relationship can be terminated by either RWJUH at Rahway or myself at any time, with or without cause or with or without notice. I also understand that no management representative has any authority to enter into any agreement guaranteeing conditions of employment or any agreement contrary to the foregoing statements. I understand that if employed by Robert Wood Johnson University Hospital at Rahway (RWJUH at Rahway), I agree to conform to the rules, regulations, policies and procedures of RWJUH at Rahway at all times and understand that such obligation is a condition of employment. I authorize my employers (unless otherwise noted on this application form), listed references, schools, law enforcement agencies, courts, and any other organization or person contacted to release to RWJUH at Rahway and/or their representatives information concerning my qualifications, employment (including the reasons for my termination), education or criminal record. I release RWJUH at Rahway and it's affiliates and employees from all liability for requesting and/or acting based on any such report and release all other parties from liability for furnishing such information. BY SUBMITTING BELOW, I ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE STATEMENTS AND CONDITIONS.