Position(s) applying for: *

Date of application: *

Name: *

Email: *

Physical address: *

Home phone: *

Mailing address: *

Cell phone: *

Are you legally entitled to work in the U.S.?

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

Have you any relatives employed here?

If yes, please provide dates:

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

If yes, please explain fully:

Do you now have or do you anticipate having any activities, commitments or responsibilities that may prevent you from meeting your work attendance requirements?

If yes, please explain:

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?

How did you learn about this employment opportunity?

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?

Shift(s): *

Status: *

Will you rotate shifts?

Will you work weekends?

Will you work overtime?

Any days you are unavailable?

List all education beginning with high school or GED.
If high school diploma or GED was not achieved, please list highest level completed:

Name and Address of School or University

Diploma/Degree Obtained (Yes/No)

Major or Subject

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?

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?

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

Typing

Phone switchboard

Bookkeeping

Medical terminology

Medicare/Medicaid

Insurance billing

Accounting

Software/computers

Word processing

Calculator

Transcription

Data entry

Ten-key adding

Reception

Other:

Floor care (manual)

Maintenance (craft)

Floor care (machines)

Dishwasher (industrial)

Electrical

Driving

Small power tools

Plumbing

Maintenance (general)

Building

Electronics

Other:

Sterile techniques

Charting

Geriatric

Vital signs

Monitor

Medical

Pre-ops prep

Intensive care

Surgical

Isolation techniques

Orthopedic

Obstetrics

Catheterization

Pediatric

Coronary care

Oncology

Other:

This section must be completed. List employment history starting with most recent and account for any time gaps, including military service. Attach additional sheet if necessary.

Employer:

Phone number:

From (month/year):

Address:

To (month/year):

Job title:

Hours per week:

Specific duties:

Supervisor:

Reason for leaving:

May we contact this employer?
YesNo

Employer:

Phone number:

From (month/year):

Address:

To (month/year):

Job title:

Hours per week:

Specific duties:

Supervisor:

Reason for leaving:

May we contact this employer?
YesNo

Employer:

Phone number:

From (month/year):

Address:

To (month/year):

Job title:

Hours per week:

Specific duties:

Supervisor:

Reason for leaving:

May we contact this employer?
YesNo

Employer:

Phone number:

From (month/year):

Address:

To (month/year):

Job title:

Hours per week:

Specific duties:

Supervisor:

Reason for leaving:

May we contact this employer?
YesNo

Employer:

Phone number:

From (month/year):

Address:

To (month/year):

Job title:

Hours per week:

Specific duties:

Supervisor:

Reason for leaving:

May we contact this employer?
YesNo

Employer:

Phone number:

From (month/year):

Address:

To (month/year):

Job title:

Hours per week:

Specific duties:

Supervisor:

Reason for leaving:

May we contact this employer?
YesNo

Skyline Hospital is an equal opportunity employer and does not discriminate in hiring based on federally-protected classifications (i.e., race, color national origin, ancestry, religion, sex, disability, veteran status, age, genetic information, or any other protected class covered under feral, state or local laws).

I certify the information set forth in this Application for Employment is true and complete to the best of my knowledge. I understand, if employed, falsified statements on this application or failure to furnish all requested information shall be considered sufficient cause for my dismissal.

I understand that this application is not intended to and does not create a contract or offer of employment.

I understand and agree, if hired, my employment would be on an at-will basis and 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 no representative of the company, other than the CEO or his designee, has authority to enter into any agreement contrary to the forgoing.

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 in addition to the pre-employment screening process established by this employer.

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.

I understand all company property must be returned on or prior to the last day of work.

Signature of applicant: *

Date: *