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Print out PDF version of the application

 

Application for Employment

We are An Equal Opportunity Employer

INSTRUCTIONS: Please furnish all information requested on this form.

Position(s) Applied For:
Date of Application:

Personal Data
Name:
Address:
City:
Phone Number:
Social Security Number:

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

Yes No

Are you a military veteran?
Yes No
If yes, please list under Work Experience.

How did you learn about this position opening?

Ad Friend Other

Have you been previously employed here?
Yes No If yes, give dates:
If yes, please indicate name(s) and in what position.

Have you been convicted of a criminal offense or been released from prison within the past ten (10) years?

(A "yes" answer to this question will not necessarily bar the applicant from employment.)

Yes No

If yes, explain fully:

Have you been debarred, excluded or otherwise ineligible for participation in federal health care programs?

Yes No

If yes, explain fully:


Optional

List any foreign language(s) and check the box that best describes your skill level.

Language
Read/Write/Speak
Read/Write
Read/Speak
Read Only
Speak Only

Work Skills

List training and/or experience which may qualify you for the position(s) desired: (mark "T" if you have training in the skill. Mark "E" if you have experience in the skill. Mark "B" if you have both training and experience.)

Business

General

Patient Care

Typing (W.P.M.)

Floor Care (Manual)
Sterile Technique

Shorthand (W.P.M.)

Floor Care (Machines)
Vital Signs
Transcription
Linen Packing
Pre-Op Preps
Medical Terminology
Autoclave
Isolation Technique
Bookkeeping
Sterilizer (Steam/Gas)
Catheterization
Accounting
Dishwasher (Manual)
Coronary Care
Ten-Key Adding
Dishwasher (Industrial)
Charting
Calculator
Sewing

Monitor (Type):

Key Punch
Maintenance (General)
Intensive Care
Invoicing/Inventory
Maintenance (Craft)
Orthopedic
Reception
Electrical
Pediatric
Phone Switchboard
Plumbing
Geriatric
Insurance Billing
Building
Medical
Medicare/Medicaid
Electronics
Surgical
Word Processing
Small Power Tools
Obstetrics

Computers

Driving

Oncology

Data Entry
Other
Other
Other

Software

Comments:

Work Availability
Full-time
Part-time
Temporary
On-call
If temporary or on-call, indicate when available:
Indicate shift(s) you will work:
   
Will you rotate shifts?
Yes No
Will you work weekends?
Yes No
Indicate days you are available for work:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Job Performance Ability

Given your knowledge, skills, education and experience, are you able to perform all the essential functions of the position for which you are applying, with or without reasonable accommodation, as set forth in the job description?

Yes No


Education
High School
 
Name, 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 or Trade
Date Attended
Did you graduate?

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.

1. Name of employer, address:

Your last job title and description:

Dates employed (mo/yr)
From To

Final Salary $

Reason for leaving?

Name of Supervisor:
Phone #
May We contact? Yes No
2. Name of employer, address:

Your last job title and description:

Dates employed (mo/yr)
From To

Final Salary $

Reason for leaving?

Name of Supervisor:
Phone #
May We contact? Yes No
3. Name of employer, address:

Your last job title and description:

Dates employed (mo/yr)
From To

Final Salary $

Reason for leaving?

Name of Supervisor:
Phone #
May We contact? Yes No
4. Name of employer, address:

Your last job title and description:

Dates employed (mo/yr)
From To

Final Salary $

Reason for leaving?

Name of Supervisor:
Phone #
May We contact? Yes No
Did you work for any of the above employers under a different name?
If so, please type in which one(s) Give previous name:

Attendance

Do you now have or do you anticipate having any activities, commitments or responsibilities that may prevent you from meeting your work attendance requirements? Yes No

If yes, please explain


Professional Registration/Licensure
Type of Registration or 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 furnish by me.

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 out of furnishing such job related information.

Signature of Applicant: Date: