Columbia Basin Hospital is an equal opportunity employer dedicated to a policy of non-discrimination in employment (including application for employment) on any basis including race, color, religion, national origin, ancestry, citizenship, sex, age, physical or mental disability, medical condition, pregnancy, veteran or military status, or any other basis prohibited by local, state, and federal law.
Applicants with disabilities may be entitled to reasonable accommodation under the terms of the Americans with disabilities act and certain state or local laws. A reasonable accommodation is a change in the way things are normally done which will ensure an equal employment opportunity without imposing undue hardship on Columbia Basin Hospital.
Please contact Human Resources if you need assistance completing this application or to otherwise participate in the application process.
READ AND ANSWER ALL QUESTIONS CAREFULLY. FAILURE TO RESPOND TO ALL QUESTIONS MAY DISQUALIFY THIS APPLICATION FROM REVIEW AND CONSIDERATION. ALL INFORMATION MUST REFLECT A COMPLETE AND ACCURATE RECORD OF YOUR EDUCATION AND EMPLOYMENT HISTORY.
* First Name: Middle Initial: * Last Name:
Present Address * Street: * City: * State: * Zip: * Phone:
Permanent Address (if different from above) Street: City: State: Zip: Phone:
* If you are under 18 years of age, can you provide proof of your eligibility to work? Yes No N/A
* Have you previously been employed here? Yes No If yes, give dates. From: To:
How did you learn about this position opening? Ad Friend Other
* Have you any relatives employed here? Yes No If yes, please indicate name(s) and in what position:
* Full-time Part-time Temporary On-call If temporary or on-call, indicate when available:
* Indicate which shifts you will work: 1st/days 2nd/evenings 3rd/nights
* Will you rotate shifts? Yes No
* Will you work weekends? Yes No
* Are you available for overtime? Yes No
* Indicate the days you are available to work: Monday Tuesday Wednesday Thursday Friday Saturday Sunday
* Have you been debarred, excluded or otherwise ineligible for participation in federal health care programs? Yes No If yes, explain fully:
* Have you been convicted of a felony or a misdemeanor in the last 7 years? Yes No (A "yes" answer to this question will not necessarily bar the applicant from employment.) If yes, explain fully:
High School Name: Major Course of Study: Location: Diploma or GED: Yes No College or Schools after high school (include any job related education or training in military service). Name, Location: Academic Major, Skill/Trade: Graduate? Yes No Name, Location: Academic Major, Skill/Trade: Graduate? Yes No Name, Location: Academic Major, Skill/Trade: Graduate? Yes No
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. Name of employer: Employer address: Dates employed (mo/yr): From: To: Final salary: $ Name of Supervisor: Supervisor Phone Number: May we contact this supervisor? Yes No Your last job title and description: Reason for leaving:
Name of employer: Employer address: Dates employed (mo/yr): From: To: Final salary: $ Name of Supervisor: Supervisor Phone Number: May we contact this supervisor? Yes No Your last job title and description: Reason for leaving:
Name of employer: Employer address: Dates employed (mo/yr): From: To: Final salary: $ Name of Supervisor: Supervisor Phone Number: May we contact this supervisor? Yes No Your last job title and description: Reason for leaving: Did you work for any of the above employers under a different name? If so, please indicate which one(s): Give your previous name:
Type of Registration/License: State: Number: Date of expiration: If you do not have a required registration or license, have you applied for one? Yes No If an examination is required, what date are you scheduled to take the examination? lf not licensed in Washington State, have you applied for reciprocity? Yes No Have you ever had a professional registration/license revoked, suspended or restricted? Yes No If yes, explain fully:
Type of Registration/License: State: Number: Date of expiration: If you do not have a required registration or license, have you applied for one? Yes No If an examination is required, what date are you scheduled to take the examination? If not licensed in Washington State, have you applied for reciprocity? Yes No Have you ever had a professional registration/license revoked, suspended or restricted? Yes No If yes, explain fully:
I certify 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 dismissal.
I understand my employment shall be contingent upon proof of identity and verification of eligibility for 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 part, for any criminal offense.
I consent to and authorize this employer and its personnel to request any information concerning my previous employment record as indicated on the 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 out 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 authority to enter into any 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 any amount necessary to satisfy any unpaid obligation.
I understand that my typed name below shall have the same force and effect as my written signature.