Program Application
APPLICATION COMPLETION INSTRUCTIONS AND CHECKLIST
/ Internship / Residency Application Completed
/ Resume – attached to application
/ Official Copy of Transcripts (as of last term completed) mailed by school to contact person below.
/ (Residency Only) - GMAT / GRE Results
/ Three (3) Completed Reference Forms – sign and give to reference with addressed stamped envelope to be returned to contact person.
(Suggested that one reference be School / Educational related, another be Church/Volunteer related, and the third work related)
/ Contact Person – Application, resume, transcripts and references should be mailed to:
Robert Wells, Director of Operational Excellence
Adventist Healthcare
1801 Research Blvd
Rockville, MD20850
Phone: (301) 315-3650, Email:
APPLICATION QUESTIONS
Section I – This section includes your contact information, current or school address, etc. and your permanent or home address information.
Section II – In this section, indicate which of the internships and/or residency programs that you are applying for and what your preferred ranking is (1 = first choice, 2 = second choice and so on).
Section III – This section explores your Computer Proficiency and other skills.
a) List computer skills including word processing, spreadsheet, database and other programs.
Section IV – This section includes your most recent educational accomplishments and your current or recent past employment. In addition to this information, you will be providing us with a current resume and official transcripts from the school.
a) Major(s) / Minor(s)
b) GPA in Major / Overall GPA
c) Major(s) / Minor(s)
Section V – This is the Career Steps and Goals section, designed to help us get to know about you and your career goals better.
a) Extracurricular activities in college, church or community: List leadership positions held.
b) List Honors, Awards, Scholarships.
c) Describe some of your general interests and hobbies.
d) What are your long-term career objectives? How are you preparing yourself to achieve them?
e) Why would you like to become an intern / resident or an employee of Adventist Healthcare?
Section VI – In this section we are seeking any comments you may have and your affidavit of authenticity.
Section I: Contact & Demographic InformationFirst Name / Middle Initial / Last Name
Email Address / Cell Phone / Other Phone
Street Mailing Address / City / State/ Zip
Section II: Program Preferences:
Please indicate which programs interest you. Rank all that apply (1 - first choice, etc.)
Internships: 12 Week Experiences / *Note Internships are typically offered after completion of junior year for undergradsor during a graduate program.
Accounting/ Finance Internship: / Management Internship:
Leadership Residences: Multi-Year Experiences / *Note Residencies are typically offered after the completion of agraduate program.
Accounting/ Finance Residency: / Management Residency: / Supply Chain Residency:
Section III: ComputerProficiency
List skills or training on computers: / Mark Proficiency Level with a “X”
Novice / Intermediate / Expert
Word Processing:
Spreadsheets(s):
Databases(s):
Other:
Other:
Section IV: Most Recent Educational Endeavor and Employment History
Please attach a Resume for complete history
College / Degree / Degree Completion Year/Month
Major(s)/ Minor(s) / GPA in Major / Overall GPA
Current or Most Recent Employer / Position/ Role / Time in Position
Section V: Career Steps and Goals
Extracurricular activities and leadership roles in College, Church or Community (List Leadership positions held)
List Honors, Awards, Scholarships
Describe some of your general interests and hobbies.
What are your long-term career objectives?
How are you preparing yourself to achieve your career objectives?
Why would you like to become an Intern/Resident at Adventist Healthcare?
Section VI: Other – Comments, Attestation
Comments
I attest that by submitting this application, I pledge that all the information on this application and requested materials are true, correct, and complete. I understand that in the event my application is accepted for consideration that I, as consideration for such review and processing authorize an investigation of all statements contained in application materials.
Signature: / Date:
has made application with Adventist Healthcare
(First Name) / (Last Name)
Leadership Development Program for either an internship or residency program opportunity. Your confidential evaluation of this individual in regard to the items listed will be appreciated.
RELEASE AUTHORIZATION – I authorize any and all persons, companies, educational institutions or agencies having personal knowledge about me, to furnish requestor with any and all information in their possession regarding me in connection with my application. I also hereby release any and all aforementioned individuals or groups responding to such investigation for any damage due to releasing any information they may have regarding me, whether or not it is in their records or otherwise available to them provided it relates to my employment history or other statement made in this application, pertaining hereto. I understand this authorization is to be part of the written employment application that I sign.
(Applicant Signature) / (Date)Instructions: Using the following guidelines please rate the applicant in the following general areas by placing an "X" in the appropriate box.
Rating / Performance Descriptor / Developmental StatusExcels / Performance significantly exceeds acceptable requirements / Model for Others
Good / Performance exceeds acceptable requirements / Strength
Average / Performance meets acceptable requirements / Acceptable
Fair / Performance less than acceptable requirements / Developmental Need
Poor / Performance significantly below acceptable requirements / Major Developmental Need
NA / Performance not demonstrated or observed / Unknown
Competency / Behavior / Excels / Good / Average / Fair / Poor / NA
Achievement orientation
Concern for quality and order
Initiative
Interpersonal skills
Impact and influence on others
Relationship building
Teamwork and cooperation
Analytical thinking
Conceptual thinking
Self-control, stress resistance
Self-confidence
Flexibility
Attitude towards supervision
Professional appearance
OVERALL RATING
Has applicant expressed interest in a health care career? / Yes / No / Unknown
Has applicant expressed interest in relocation for professional growth? / Yes / No / Unknown
(over)
Additional Questions:List applicant's areas of strength, or areas that they have been an example for others:
List applicant's developmental needs or area where growth is needed.
Additional Comments:
Reference Completed by:
(Signature) / (Print Name) / (Date)
Relationship to Applicant: (Check One):
Department / Division Chair of:
Professor of:
Employer:
Professional Associate (describe):
Church Related (Pastor or other):
Other (specify):
Please return to: Robert Wells, Director of Operational Excellence
Adventist Healthcare, 1801 Research BlvdRockville, MD20850
Phone: (301) 315-3650, Email:
Thank you for taking the time to provide your assessment of this candidate. Your opinions are very valuable in helping us to match applicants with placement openings.
has made application with Adventist Healthcare(First Name) / (Last Name)
Leadership Development Program for either an internship or residency program opportunity. Your confidential evaluation of this individual in regard to the items listed will be appreciated.
RELEASE AUTHORIZATION – I authorize any and all persons, companies, educational institutions or agencies having personal knowledge about me, to furnish requestor with any and all information in their possession regarding me in connection with my application. I also hereby release any and all aforementioned individuals or groups responding to such investigation for any damage due to releasing any information they may have regarding me, whether or not it is in their records or otherwise available to them provided it relates to my employment history or other statement made in this application, pertaining hereto. I understand this authorization is to be part of the written employment application that I sign.
(Applicant Signature) / (Date)Instructions: Using the following guidelines please rate the applicant in the following general areas by placing an "X" in the appropriate box.
Rating / Performance Descriptor / Developmental StatusExcels / Performance significantly exceeds acceptable requirements / Model for Others
Good / Performance exceeds acceptable requirements / Strength
Average / Performance meets acceptable requirements / Acceptable
Fair / Performance less than acceptable requirements / Developmental Need
Poor / Performance significantly below acceptable requirements / Major Developmental Need
NA / Performance not demonstrated or observed / Unknown
Competency / Behavior / Excels / Good / Average / Fair / Poor / NA
Achievement orientation
Concern for quality and order
Initiative
Interpersonal skills
Impact and influence on others
Relationship building
Teamwork and cooperation
Analytical thinking
Conceptual thinking
Self-control, stress resistance
Self-confidence
Flexibility
Attitude towards supervision
Professional appearance
OVERALL RATING
Has applicant expressed interest in a health care career? / Yes / No / Unknown
Has applicant expressed interest in relocation for professional growth? / Yes / No / Unknown
(over)
Additional Questions:List applicant's areas of strength, or areas that they have been an example for others:
List applicant's developmental needs or area where growth is needed.
Additional Comments:
Reference Completed by:
(Signature) / (Print Name) / (Date)
Relationship to Applicant: (Check One):
Department / Division Chair of:
Professor of:
Employer:
Professional Associate (describe):
Church Related (Pastor or other):
Other (specify):
Please return to: Robert Wells, Director of Operational Excellence
Adventist Healthcare, 1801 Research BlvdRockville, MD20850
Phone: (301) 315-3650, Email:
Thank you for taking the time to provide your assessment of this candidate. Your opinions are very valuable in helping us to match applicants with placement openings.
has made application with Adventist Healthcare(First Name) / (Last Name)
Leadership Development Program for either an internship or residency program opportunity. Your confidential evaluation of this individual in regard to the items listed will be appreciated.
RELEASE AUTHORIZATION – I authorize any and all persons, companies, educational institutions or agencies having personal knowledge about me, to furnish requestor with any and all information in their possession regarding me in connection with my application. I also hereby release any and all aforementioned individuals or groups responding to such investigation for any damage due to releasing any information they may have regarding me, whether or not it is in their records or otherwise available to them provided it relates to my employment history or other statement made in this application, pertaining hereto. I understand this authorization is to be part of the written employment application that I sign.
(Applicant Signature) / (Date)Instructions: Using the following guidelines please rate the applicant in the following general areas by placing an "X" in the appropriate box.
Rating / Performance Descriptor / Developmental StatusExcels / Performance significantly exceeds acceptable requirements / Model for Others
Good / Performance exceeds acceptable requirements / Strength
Average / Performance meets acceptable requirements / Acceptable
Fair / Performance less than acceptable requirements / Developmental Need
Poor / Performance significantly below acceptable requirements / Major Developmental Need
NA / Performance not demonstrated or observed / Unknown
Competency / Behavior / Excels / Good / Average / Fair / Poor / NA
Achievement orientation
Concern for quality and order
Initiative
Interpersonal skills
Impact and influence on others
Relationship building
Teamwork and cooperation
Analytical thinking
Conceptual thinking
Self-control, stress resistance
Self-confidence
Flexibility
Attitude towards supervision
Professional appearance
OVERALL RATING
Has applicant expressed interest in a health care career? / Yes / No / Unknown
Has applicant expressed interest in relocation for professional growth? / Yes / No / Unknown
(over)
Additional Questions:List applicant's areas of strength, or areas that they have been an example for others:
List applicant's developmental needs or area where growth is needed.
Additional Comments:
Reference Completed by:
(Signature) / (Print Name) / (Date)
Relationship to Applicant: (Check One):
Department / Division Chair of:
Professor of:
Employer:
Professional Associate (describe):
Church Related (Pastor or other):
Other (specify):
Please return to: Robert Wells, Director of Operational Excellence
Adventist Healthcare, 1801 Research BlvdRockville, MD20850
Phone: (301) 315-3650, Email:
Thank you for taking the time to provide your assessment of this candidate. Your opinions are very valuable in helping us to match applicants with placement openings.