Employment Application

Personal Information
Position Applied For *
First Name *
Last Name *
Address Line 1 *
Address Line 2
City *
State *
Zip Code *
Primary Phone Number *
eMail Address
If you are under 18, can you provide proof of your eligibility to work?	Yes No
How did you hear about this position?
Do you have any relatives employed here? *	Yes No
If Yes, list names and positions
Have you been previously employed here? *	Yes No
If Yes, give dates
Have you been convicted of a felony or misdemeanor? *	Yes No
If Yes, explain fully
Have you been in any way excluded from participation in federal healthcare programs? *	Yes No
If Yes, explain fully
Optional
If you know any foreign languages, enter them below and check the boxes that apply to your skill level.
Spanish	Read Write Speak
Language
Skills in the above	Read Write Speak
Language
Skills in the above	Read Write Speak
Work Availability
Which schedules would you be willing to work?	Regular Short-term Full-time Part-time On-call
Would you be willing to work overtime?	Yes No
Which shifts would you be willing to work?	Shift 1 (days) Shift 2 (evenings) Shift 3 (nights)
Are you willing to rotate shifts?	Yes No
Are you willing to work weekends?	Yes No
Please check the days you are available to work	Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Education
High School name & location
Have you received your high school diploma or GED? *	Yes No

Please enter additional education information:
Institution 1 Name and Location
Major or Trade Skill
Beginning date:	(calendar)
Ending date:	(calendar)
Degree received

Institution 2 Name and Location
Major or Trade Skill
Beginning date:	(calendar)
Ending date:	(calendar)
Degree received

Institution 3 Name and Location
Major or Trade Skill
Beginning date:	(calendar)
Ending date:	(calendar)
Degree received
Work Experience
Please list your most recent employer first, and account for at least the past 5 years of employment history.
If there are any gaps in your employment history, please explain:
If you have been employed under a different name, please enter that name

Name and location of most recent employer
Date employment begun:	(calendar)
Date employment concluded: (enter today's date if still employed)	(calendar)
Final wage or salary:
Immediate supervisor's name
Job Title
Job Duties
Why did you leave this job?
Contact number
May we contact this employer?	Yes No

Name and location of previous employer
Date employment begun:	(calendar)
Date employment concluded:	(calendar)
Final wage or salary:
Immediate supervisor's name
Job Title
Job Duties
Why did you leave this job?
Contact number
May we contact this employer?	Yes No

Name and location of previous employer
Date employment begun:	(calendar)
Date employment concluded:	(calendar)
Final wage or salary:
Immediate supervisor's name
Job Title
Job Duties
Why did you leave this job?
Contact number
May we contact this employer?	Yes No
Professional Registration/Licensure
If you have any professional registrations or licenses, please enter them below.
Type of registration/license
State
Number
Date of expiration:	(calendar)

Type of registration/license
State
Number
Date of expiration:	(calendar)

Type of registration/license
State
Number
Date of expiration:	(calendar)

If you do not have a required registration or license, have you applied for one?	Yes No
If an examination is required, for what date have you scheduled the exam?	(calendar)
If not licensed in WA state, have you applied for reciprocity?	Yes No
Additional Information
If you would like to attach a resume or cover letter, you may do so here in RTF, DOC, or PDF:
Authorization/Agreement
I certify that the information set forth in this Application for Employment is true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application or failure to furnish all requested information shall be sufficient cause for my dismissal.
I understand that my employment shall be contingent upon proof of identity and verification of eligibility of employment in the United States in accordance with the Immigration Reform and Control Act of 1986. I further understand that my employment is contingent upon the checking of references furnished by me, and contingent upon a background check performed by a third party, for any criminal offenses, and contingent on a negative drug and/or alcohol test result.
I consent to and authorize this employer and its personnel to request any information concerning my previous employment record as indicated on this Application for Employment. I hereby release all parties and persons connected with any request for information from all claims, liabilities, and damages for whatever reason arising our of furnishing such job-related information.
I understand and agree that my employment and compensation may be terminated at any time without prior notice, with or without cause, at the option of the company or myself, and understand that no representative of the company, other than the Administrator, has any authority to enter into an agreement contrary to the foregoing.
I understand that all company property must be returned and any indebtedness to the company must be paid on or before my last day of work. I authorize the company to deduct from my final paycheck an amount necessary to satisfy any unpaid obligation.
My typed name below shall have the full force and effect of my written signature.
I agree to the above terms and would like to submit my application for consideration:

Phone: (509) 826-1760
Fax: (509) 826-7211
E-Mail: webmaster@mvhealth.org

Our Address:

Mid-Valley Hospital
810 Jasmine St
PO Box 793
Omak, WA 98841

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