Employment

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Applications are accepted for open positions only.

This facility is an equal opportunity employer. We recruit, hire, train and promote without discrimination due to race, color, religion, sex, national origin, ancestry, marital status, age or disability.

Any offer of employment is contingent upon verification of information provided on this application, satisfactory completion of background checks, and passing a physical examination.

* - denotes required item

Please Enter All Required Information
First Name:
*
Middle Name:
Last Name:
*
Other names by which you have been known:
Email address:
*
Address:
*
City:
*
State:
*
Zip:
*
Phone #:
*
Alt. Phone #:
Position Applied For:
*
Seeking:
Full-time Day  
Part-time Evening Temp.
PRN/Casual Night  
Are you available to work weekends?:
Yes No
Date you can start:
*
Have you previously been employed by this hospital?:
Yes No  
When:
Supervisor:
Do you have a legal right to work in the US?:
Yes No *
List any relatives who are currently employed at Humboldt Hospital:
Do you have a record of founded child or dependent adult abuse?: Yes No *
Have you ever been convicted of a health care related crime for which mandatory exclusion could be imposed, including Medicare and State health care program-related crimes, patient abuse, or felonies related to health care fraud or controlled substances?: Yes No *
Have you ever been convicted of a crime in this State or any other State?: Yes No *
If Yes, to any question please explain:
A conviction record will not necessarily be a bar to employment. Background checks may be completed.
Education
School Attended:
Years Attended:
City:
State:
Degree or Certification:
School Attended:
Years Attended:
City:
State:
Degree or Certification:
PROFESSIONAL LICENSURE, REGISTRY, CERTIFICATION
Copy required upon employment.
Type of License, Registry or Certification:
Number:
Expiration Date:
Issuing State or Organization:
Type of License, Registry or Certification:
Number:
Expiration Date:
Issuing State or Organization:
If not currently registered, licensed, or certified, are you eligible?: Yes No
When will you/did you sit for your examination?:
SPECIAL SKILLS
Personal Computer  
Word Processing  
Medical Terminology  
Hardware used:
Software used:
Other Special Skills:
ADDITIONAL INFORMATION
Please include any additional information that you think would be applicable: e.g. internships, membership in professional organizations, additional relevant employment, and explanation of any gaps in employment, EXCLUDE any information which would denote race, sex, age, marital status, national origin, religious or political affiliations.
Did someone make you aware of this position? If yes, please give name:
EMPLOYMENT HISTORY
Please list your job history starting with your present or most recent employment and noting any periods in which you were not employed in the section marked "Additional Information." Please include military service; do not include internships in this section.
Name and Address of Employer
Name:
Address:
Immediate Supervisor  
Name:
Title:
If present employer, may we contact?:
Yes No
From (Month/Year):
To (Month/Year):
Salary:
Status:
FT PT
Position Title:
Describe your principal duties or responsibilities:
Reason for leaving:
Name and Address of Employer
Name:
Address:
Immediate Supervisor  
Name:
Title:
From (Month/Year):
To (Month/Year):
Salary:
Status:
FT PT
Position Title:
Describe Your Principal Duties or Responsibilities:
Reason for Leaving:
Name and Address of Employer
Name:
Address:
Immediate Supervisor  
Name:
Title:
From (Month/Year):
To (Month/Year):
Salary:
Status:
FT PT
Position Title:
Describe Your Principal Duties or Responsibilities:
Reason for Leaving: