Healthcare Employment Application | Community Memorial Hospital

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In person at the Human Resources Department (Download PDF)

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Step 1 of 6 - Personal Information

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Personal Information

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Position applying for*

Position*

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Cell Phone Number*

Home Phone Number

Email*

Upload Resume

Drop files here or

Accepted file types: doc, docx, pdf, jpg, jpeg, png, gif, Max. file size: 8 MB, Max. files: 3.

Basic Questions

All sections must be completed and application must be signed

Date available for work*

MM slash DD slash YYYY

I am available to work:

Check all that apply

Full-Time

Part-Time

Per Diem

Shift availability:*

Check all that apply

First Shift

Second Shift

Third Shift

Have you ever filed an application with us before?*

Yes

Date of application:*

Have you ever been employed with us before?*

Yes

Dates of employment:*

Were you referred by a CMH employee?*

Yes

Which employee?*

Are any friends or relatives currently or previously an employee of CMH?*

Yes

What is their name?*

Relationship*

Department or unit*

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

Yes

Are you a U.S. Citizen?*

Yes

Have you been convicted of a crime?*

This includes felonies, misdemeanor, and DWI's

Yes

Please explain*

Were you ever excluded or are you pending exclusion from billing Medicaid or Medicare?*

Yes

Have you ever been disciplined at a job for attendance problems?*

Yes

Have you ever been discharged or requested to resign from a position?*

Yes

Please explain*

How did you learn about CMH?*

Professional License Number

Certificate Number

Registration Number

Describe any specialized training or skills (language, computer, equipment, etc.):

Employment History

List all employment starting with your current or most recent employer. Account for all periods, including unemployment and Armed Services. Please answer all questions completely.

Employer

Phone Number

Address

Street Address Address Line 2 City State ZIP Code

Supervisor

From

MM slash DD slash YYYY

Reason for leaving

Terminated

Resigned

Still employed

Job Title

Responsibilities

May we contact your previous employer?

Yes

Employer

Phone Number

Address

Street Address Address Line 2 City State ZIP Code

Supervisor

From

MM slash DD slash YYYY

Reason for leaving

Terminated

Resigned

Still employed

Job Title

Responsibilities

May we contact your previous employer?

Yes

Employer

Phone Number

Address

Street Address Address Line 2 City State ZIP Code

Supervisor

From

MM slash DD slash YYYY

Reason for leaving

Terminated

Resigned

Still employed

Job Title

Responsibilities

May we contact your previous employer?

Yes

Military Service

Branch

From

MM slash DD slash YYYY

Rank at discharge

Type of discharge

Professional References

Company Name

Address

Street Address Address Line 2 City State ZIP Code

Phone Number

Supervisor Name

First Last

Company Name

Address

Street Address Address Line 2 City State ZIP Code

Phone Number

Supervisor Name

First Last

Personal References

Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone Number

Occupation

Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone Number

Occupation

Will you now, or in the future, require visa sponsorship for employment from Community Memorial Hospital?*

Yes

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

We are required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress of our workforce of individuals with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years.

Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations under Section 503 of the Rehabilitation Act, (OFCCP) website at https://www.dol.gov/ofccp/.

How do you know if you have a disability? You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to: Autism Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS Blind or low vision Cancer Cardiovascular or heart disease Celiac disease Cerebral palsy Deaf or hard of hearing Depression or anxiety Diabetes Epilepsy Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome Intellectual disability Missing limbs or partially missing limbs Nervous system condition for example, migraine headaches, Parkinson’s disease, or Multiple sclerosis (MS) Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression Disability Status?(optional)

Disability Answer*

I don't wish to answer

No, I don't have a disability, or a history/record of having a disability

Yes, I have a disability, or have a history/record of having a disability

If you believe you belong to any of the categories of protected veterans listed below, please indicate by making the appropriate selection. As a government contractor subject to the Vietnam Era Veterans Readjustment Assistance Act (VEVRAA), we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.

Classification of protected categories is as follows:

A "disabled veteran" is one of the following: a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or a person who was discharged or released from active duty because of a service-connected disability.

A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.

An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.

An "Armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985. Veteran Status? (optional)

Veteran Answer*

I don't wish to answer

I identify as one or more of the classifications of a protected veteran

I am not a protected veteran

Race/Ethnicity (optional)*

American Indian/Alsaka Native

Asian

Black or African/American

Hispanic or Latino

Chose not to Disclose

Hawaiian or Pacific Islander

Two or more races

White

For government reporting purposes, we ask candidates to respond to the below self-identification survey. Completion of the form is entirely voluntary. Whatever your decision, it will not be considered in the hiring process or thereafter. Any information that you do provide will be recorded and maintained in a confidential file.

As set forth in Community Memorial Hospital’s Equal Employment Opportunity policy, we do not discriminate on the basis of any protected group status under any applicable law. Gender? (optional)

Self Identify Answer*

Decline To Self-Identify

Female

Male

Employment Application Agreement

It is understood that an omission of facts or false statements made as part of the application process will be grounds for dismissal from any subsequent employment by Community Memorial Hospital.

Furthermore, I understand that just as I am free to resign at any time, the employer reserves the right to terminate my employment at any time with or without cause and without prior notice. I understand that no representative of the employer has the authority to make any assurances to the contrary. As part of pre-employment, I authorize CMH to contact my references and to otherwise investigate my suitability for employment by contacting any of the following sources: educational institutions, law enforcement agencies, military services and former employers. I release said contacts and CMH from any and all liability resulting from such investigation CMH is an equal opportunity employer. The employer does not discriminate in employment on account of race, color, religion, national origin, citizenship status, ancestry, age, sex (including sexual harassment), sexual orientation, material status, physical or mental disability, military status or unfavorable discharge from military service, and no question on this application is used for the purpose of limiting or excluding any applicant’s consideration for employment on a basis prohibited by local, state or federal law.

I understand that my employment with CMH is contingent upon successfully completing the pre-employment health screen.

Signature*

Date*

MM slash DD slash YYYY

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Comments

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Job Application

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Personal Information

Basic Questions

Education

High School

Undergraduate College

Graduate/Professional School

Other

Additional Information

Employment History

Military Service

Professional References

Personal References

Voluntary Self-Identification of Disability

Employment Application Agreement

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