Apply for a Job - Powell Valley Healthcare

Personal Information

It is the policy of this facility to provide equal opportunity to persons regardless of race, religion, age, gender, disability or any other classification in accordance with federal, state and local statutes, regulations and ordinances. This application can be active as long as legally required.

First Name *

Middle Name

Last Name *

Are you at least 18 years old? *

Yes

No

Email *

Phone *

Secondary Phone

Current Address *

Country

City

State

Zip code

Previous Address

Country

City

State

Zip code

Background Information

If other, please explain

Have you ever been employed by this facility? *

Yes

No

If yes, please provide position and dates of employment

Do you have a friend or relative working at this facility? *

Yes

No

If yes, please provide name(s) of friend(s) or relative(s)

Have you been convicted of a crime and/or released from confinement following a conviction for any criminal offense? Arrests or charges that have been expunged need not be disclosed. *

Yes

No

If yes, please explain

Are you presently charged with any violation of the law? *

Yes

No

If yes, please provide date, place, and nature of each such event

Are you currently excluded from participation in any federally funded healthcare program–including Medicare and Medicaid–and are you aware of any potential exclusion from a federally funded health program? *

Yes

No

Are you legally authorized to work in the U.S.? *

Yes

No

Position Information

Position Applying For *

Date available to begin work *

Salary Requirement *

Availability *

Full-time

Part-time

PRN

(check all that apply)

Are you willing and able to work the following? *

Day shift

Night shift

Evening shift

Weekends

(check all that apply)

Education Information

Highest Grade Completed *

Diploma/Degree obtained? *

Yes

No

If yes, please list the degree you received

Please list any professional licenses, registration or certifications you possess (include driver's license, if applicable)

Make sure to include type, state issued, expiration date and number. Indicate if any licenses have been revoked, suspended or placed on probation. Also indicate if you are ineligible to become licensed or certified in your field and, if so, explain.

Education (1st)

Education Type *

School Name *

City *

State *

Education (2nd)

Education Type

School Name

City

State

Education (3rd)

Education Type

School Name

City

State

Employment History

Please list all positions held in the last 10 years beginning with the most current position.

Most Recent Employer

Employer Name *

May we contact your present employer? *

Yes

No

Address *

Country

City

State

Zip code

Phone *

Email *

Supervisor's Name/Title

Name While Employed *

Job Title *

Current Salary *

Type of Position *

Number of Hours

Date Started *

Date Left

Description of Duties *

Reason for Leaving *

Previous Employer (1st)

Employer Name

May we contact this employer?

Yes

No

Address

Country

City

State

Zip code

Phone

Email

Supervisor's Name/Title

Name While Employed

Job Title

Current Salary

Type of Position

Number of Hours

Date Started

Date Left

Description of Duties

Reason for Leaving

Previous Employer (2nd)

Employer Name

May we contact this employer?

Yes

No

Address

Country

City

State

Zip code

Phone

Email

Supervisor's Name/Title

Name While Employed

Job Title

Current Salary

Type of Position

Number of Hours

Date Started

Date Left

Description of Duties

Reason for Leaving

Professional References

Reference (1st)

Name *

Position *

Number of years known *

Phone *

Email *

Address

Country

City

State

Zip code

Reference (2nd)

Name *

Position *

Number of years known *

Phone *

Email *

Address

Country

City

State

Zip code

Supplemental Documents

If you would like to include a cover letter and resume, please load the appropriate documents in the fields below. You may submit your application without a resume or cover letter.

Cover Letter

Resume

Applicant invitation to self-identify

This company is subject to Executive order 11246, as amended, which requires federal government contractors to ensure that applicants are employed and that employees are treated during employment without regard to their race, color, religion, sex, or national origin. We are therefore requesting information about the race and sex of our applicants in order to comply with government reporting requirements and in order to ensure equal employment opportunity.

This company is also subject to the Rehabilitation Act of 1973 Section 503 and Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended, which requires federal government contractors to take affirmative action to employ and advance in employment covered veterans. If you are a covered veteran (see definitions below) and would like to be considered under the affirmative action program, please tell us. You may inform us of your desire to benefit under the program at this time or at any time in the future.

Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will only be used in ways that are not inconsistent with the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, and Executive Order 11246, as amended. This information will be maintained separately from your application for employment.

Gender

Race

White

Black of African American (A person having origins in any of the black racial groups of Africa.)

Hispanic or Latino

Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.)

Native Hawaiian/Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)

Two or more races (not Hispanic or Latino)

Disability Self-identification

I am not a person with a disability.

I am a person with a disability.

I am a person with a severe disability.

The information will be treated as confidential. It will be used for affirmative action reporting only. The Americans with Disabilities Act of 1990 (ADA) defines a person with a disability as a person who has a physical or mental impairment that substantially limits one or more major life activities. Examples of major life activities are: hearing, seeing, speaking, breathing, performing manual tasks, walking, caring for oneself, learning or working. [29 C.F.R.S1630.2(i)]

Veteran Self-identification

I am not a Veteran

Vietnam-era Veteran

Other protected Veteran. A Veteran who served on active duty in the Armed Forces during a war or in a campaign or expedition for which a campaign badge has been authorized.

Recently separated Veteran. "Recently separated" is defined as the one-year period beginning on the date of such Veteran's discharge or release from active duty.

Applicant's Certification

I certify that the answers given on this application and during potential interviews are true and complete. I also certify that I have not been convicted of an offense that would preclude my employment in a healthcare facility and that would not exclude me from participating in federal healthcare programs. I authorize the investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with Powell Valley Healthcare is of an “at will” nature, which means that the employee may resign at any time and Powell Valley Healthcare may terminate the employee at any time.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in termination. I understand, also, that I am required to abide by all policies and procedures of Powell Valley Healthcare.

This application shall be considered active for a period of time not to exceed 60 days. Powell Valley Healthcare is an equal opportunity employer and will not discriminate in any phase of employment.

I also understand that this status can only be altered by a written contract of employment which is specific as to all material terms and is signed by me and the administrator.

Release

I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the registrar/placement office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my licensure status and my licensure history.

Important notice to all applicants

If you are selected for employment you must be prepared to verify your eligibility to work as required under the Immigration Reform and Control Act. This requirement applies to all new employees, including US citizens, permanent residents and non-immigrants. You will have to provide documents verifying your identity and eligibility to work.

Agreement *

I have read and understand these conditions of employment. By clicking the "Submit" button below, I agree that all of the preceding questions are answered truthfully and to the best of my abilities.

Signature *

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