Position Applied For

Personal Data

Please furnish all information requested on this form. If you wish to supply additional education or work history information, submit separate sheet.

Name

First Name

Last Name

Your Phone Number

(###)

###

####

Physical Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing Address

If different than physical

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

If you are under 18 years of age, can you provide required proof of eligbility to work?

Yes

Are you a military veteran?

If yes, please list under Work Experience section.

Yes

How did you learn about this position opening?

Ad in newspaper

Hospital Website

Friend/Family Member

Other

Do you have any relatives employed here?

If yes, please indicate name(s), and what position they hold.

Yes

Name & Department of Family Members Employed at NVHD

Have you been previously employed here?

If yes, please list dates and position(s) below.

Yes

If yes, please list dates and position(s) below.

Work Skills

Please mark each box that describes your experience/training.

Other Business Experience/Training

Other General Experience/Training

Other Patient Care Experience/Training

Work Availability

If temporary or on-call, indicate when available.

Full-time

Part-time

Temporary

On-call

Indicate shift(s) you will work

1st Shift (days)

2nd Shift (evenings)

3rd Shift (nights)

Will you rotate shifts?

Yes

Will you work weekends?

Yes

Indicate days you are available to work.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Job Performance Ability

Are you able to perform all the essential function of the postition for which you are applying?

Yes

Personal References

Reference 1

Please include first and last name, and phone number.

Reference 2

Please include first and last name, and phone number.

Reference 3

Please include first and last name, and phone number.

Education

High School

Did you earn your diploma or GED?

Yes

College or Schools after high school.

This includes any job related education or training in military service.

College Name

Academic Major, Skill or Trade

Dates Attended

College Name

Academic Major, Skill or Trade

Dates Attended

Work Experience

List most recent employer first. Include at least past five (5) years, and account for any time gaps in your employment history, including any military service. (Attach additional if ncessary.)

Name of Employer

Employer's Phone Number

(###)

###

####

Employer's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Dates Employed

Name of Supervisor & Phone Number

May we contact this supervisor?

Yes

Last job title & description

Reason For Leaving

Name of Employer

Employer's Phone Number

(###)

###

####

Employer Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Dates Employed

Name of Supervisor & Phone #

May we contact?

Yes

Your last job title & description

Reason for leaving?

Name of Employer

Employer's Phone Number

(###)

###

####

Employer Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Dates Employed

Name of Supervisor & Phone #

May we contact?

Yes

Your last job title & description

Reason for leaving

Did you work for any of the above employers under a different name?

If so, please list previous name(s) and which employer knows you as this name.

Are there any responsibilities that will prevent you from meeting attendance requirements?

If yes, please explain.

Yes

Possible Attendance Conflicts

If you answered yes on the previous question, please explain what commitments will affect your ability to meet the attendance requirements.

PROFESSIONAL REGISTRATION/LICENSURE

Please list type of registration or license, which state your licensed in, exp. date, and license #

If you do not have a required registration or license, have you applied for one?

Yes

If an exam is required, what dates are you scheduled to take the examination?

If not licensed in Washington State, have you applied for reciprocity?

If yes, please explain in the next section.

Yes

If you answered yes to the previous question, please explain.

Have you been convicted of, or do you have charges pending for any crime?

Yes

If "yes", give the crime, the conviction date or charge status and the state where it occurred.

Please ready carefully:

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 considered sufficient cause for my dismal. I understand my employment shall be contingent upon proof of identity and verification of eligibility for employment in the United States in accordance with Immigration reform and Control Act of 1986. I further understand that my employment is contingent upon the checking of references furnished by me, any results of a Criminal History Information check concerning any convictions for any crime against person, or any civil adjudication for sexual assault, physical abuse or exploitation of a minor, and positive testing results for illegal drug use. I consent to and authorize this employer and its personnel to request information concerning my previous employment record as indicated on this Application and conduct Criminal History Information check concerning any conviction for any crime against persons, or any civil adjudication for sexual assault, physical abuse or exploitation of a minor and to drug/alcohol screening. I hereby release all parties and persons connected with any request for information from all claims, liabilities, and damages for whatever reason arising out of furnishing such job related information. North Valley Hospital is an equal opportunity employer and does not discriminate on the basis of gender, age, race or color, religion, marital status, national origin, disability or veteran status, sexual orientation or gender preference. Interviews are given on a competitive basis, using job-related factors, after a written application has been received and reviewed. Because of the large number of applications received, not everyone who applies for an open position will be interviewed.

I agree and understand this statement.

Yes

All fields marked with an asterisk* MUST be completed before submitting the application. If there are incomplete fields the application will not be successfully sent, so you must go back through and check for any sections highlighted in red and complete them. If you are having problems submitting your application please call 509-486-3163 for assistance.

My typed name below shall have the full force and effect of my written signature.

Type your full name below, which acts as an electronic signature.

Thank you for your application. We will be in touch with you shortly.

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(509)486-2151 | nvhospital.org

203 S. Western Avenue, Tonasket, WA 98855

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