First Name*
Last Name*
Email Address*
Phone*
Please list at least three previous employers giving the following information:
Please list level of education, school name, degrees, licenses or certifications including State, License/Certification #, Issue Date and Expiration Date:
Do you have current CPR/BLS certification? If so please list expiration date:
Do you have a current medical license or certificate for the job you applying for?*
-- No answer -- Yes No
Have you ever been terminated from a position? If yes please explain:
Is there any information we would need about your name, or use of another name, for us to be able to check your work record?
Branch of Military Service:
I certify that all information furnished on this Application for Employment is true to the best of my knowledge. I understand that, if a contingent offer is made, falsified statements on this application or failure to satisfactorily pass a required job function screening, which includes a physical examination, drug screening, and background screening, shall be considered failure to meet necessary conditions of employment and any offer of employment will be non-binding. Initial _____
I understand that 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. Also, pursuant to the Child/Adult Abuse Information Act, and other applicable laws, I agree that my background may be checked by Clark Fork Valley Hospital and Montana Law Enforcement Authorities for any criminal history information. Initial _____
I authorize Clark Fork Valley Hospital to contact past employers and schools to obtain reference information. I will not hold Clark Fork Valley Hospital or any of its employees, medical staff or governing board members, previous employers, or schools responsible for any liability arising out of these inquiries. Depending upon review of any and all history of criminal activity, CFVH has the right to determine within or not such history is cause for offer being pre-empted. Initial _____
I agree to read and abide by the policies and procedures of Clark Fork Valley Hospital. Initial _____
"The following information is requested by the Federal Government in order to monitor compliance with Federal laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the racial/national origin of the individual applicants on the basis of visual observation or surname.
