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Application for Employment

Position(s) applying for: *
Date of application: *

Instructions: Please type or clearly print all information requested on this application. If you wish to supply additional education or work history information and do not have adequate space, please attached a separate sheet. Remember to include phone numbers of contacts under the Work History section. Completed applications can be sent to: Skyline Hospital Human Resources Department, PO BOX 99, White Salmon, 98672, jessieramos@skylinehospital.org or faxed to 509-493-5114. Incomplete applications will not be processed.

Personal Data

Name: *
Email: *
Physical address: *
Home phone: *
Mailing address: *
Cell phone: *
Are you legally entitled to work in the U.S.?
YesNo
If under 18 years of age, can you provide proof of your eligibility to work?
YesNo
Have you any relatives employed here?
YesNo
If yes, please provide dates:
Have you been debarred, excluded or otherwise ineligible for participation in federal health care programs?
YesNo
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?
YesNo
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?
YesNo
How did you learn about this employment opportunity?

Availability

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?
YesNo
Shift(s): *
1st shift – day2nd shift – evening3rd shift – night
Status: *
Full-timePart-timePer Diem/On Call
Will you rotate shifts?
YesNo
Will you work weekends?
YesNo
Will you work overtime?
YesNo
Any days you are unavailable?

Post-Secondary Education, Training and/or Military Experience

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
YesNo
YesNo
YesNo

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?
YesNo
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?
YesNo

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, “E” if you have experience in the skill or “B” if you have both training and experience in the skill.

Business

Typing
Phone switchboard
Bookkeeping
Medical terminology
Medicare/Medicaid
Insurance billing
Accounting
Software/computers
Word processing
Calculator
Transcription
Data entry
Ten-key adding
Reception
Other:

General

Floor care (manual)
Maintenance (craft)
Floor care (machines)
Dishwasher (industrial)
Electrical
Driving
Small power tools
Plumbing
Maintenance (general)
Building
Electronics
Other:

Patient Care

Sterile techniques
Charting
Geriatric
Vital signs
Monitor
Medical
Pre-ops prep
Intensive care
Surgical
Isolation techniques
Orthopedic
Obstetrics
Catheterization
Pediatric
Coronary care
Oncology
Other:

Work Experience

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 1

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 2

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 3

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 4

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 5

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 6

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

Upload Additional Files

Consent and Authorization

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: *