Mountain View Hospital Application

Mountain Vew Hospital is an equal opportunity employer. Applicants are considered for positions without regard to race, religion, sex, national origin, age, disability, or any other classification protected by law. Each question should be fully and accurately answered. No action can be taken on this application until all questions have been answered. Attach additional pages if you do not have enough room on this application. Please print/type when filling out the application and sign where indicated on the second page. All information given will be held in strict confidence.

This application will remain on file for a period of 12 months. If any of your information changes during that time or you wish to apply for other positions, please submit an updated application.

General Information

Last Name:     First Name:
Telephone:     Job applied for:
Present Address:     Date Available:
City:     Type of employment: Full-time
Part-time
Temporary or Summer
State:    Zip:   


Were you referred to MVH by a current employee? Yes No
 How did you hear about the job?    Newspaper mvhjobs.com
Other internet source
Radio TV
Family Other
Employees Name:

Record of Employement

Current/Most Recent Employer

Name        Type of Business:
Address:     Telephone:
City:    
State:    Zip:   

Dates Employed:       From (MM/YY):    To (MM/YY):
Rate of Pay: Starting: Ending:
Reason for Leaving:
Supervisor's Name and Title:
Job Title and Duties:

Next Previous Employer

Name        Type of Business:
Address:     Telephone:
City:    
State:    Zip:   

Dates Employed:       From (MM/YY):    To (MM/YY):
Rate of Pay: Starting: Ending:
Reason for Leaving:
Supervisor's Name and Title:
Job Title and Duties:

Next Previous Employer

Name        Type of Business:
Address:     Telephone:
City:    
State:    Zip:   

Dates Employed:       From (MM/YY):    To (MM/YY):
Rate of Pay: Starting: Ending:
Reason for Leaving:
Supervisor's Name and Title:
Job Title and Duties:

Next Previous Employer

Name        Type of Business:
Address:     Telephone:
City:    
State:    Zip:   

Dates Employed:       From (MM/YY):    To (MM/YY):
Rate of Pay: Starting: Ending:
Reason for Leaving:
Supervisor's Name and Title:
Job Title and Duties:

Next Previous Employer

Name        Type of Business:
Address:     Telephone:
City:    
State:    Zip:   

Dates Employed:       From (MM/YY):    To (MM/YY):
Rate of Pay: Starting: Ending:
Reason for Leaving:
Supervisor's Name and Title:
Job Title and Duties:

Unemployment Record

Account for periods of unemployment for two (2) weeks or more during the past seven (7) years.

Period: Explain:
Period: Explain:
Period: Explain:

General Questions

Have you ever been convicted of, pleaded guilty to, or pleaded no contest to a felony or misdemanor? Yes No
If yes, briefly describe the nature of the crime(s), and the date and place of conviction:
Are you currently out on bail, the subject of a current warrant for arrest, or released on your own recongnizance pending trial? Yes No
If yes, briefly explain:
(*Note: All application will be subject to a background screning and a conviction will not necessarily disqualify an application.)
Are you over 18 years of age? Yes No
Are you a citizen of the United States
or do you have a valid work permit?
(Federal law requires proof of identity and employment authorization for all new employees.) 		Yes No
For Driving Job Duty Only: Do you have a valid driver's license? Yes No
License #:
State Issued:
Are you a relative of a Mountain View Hospital employee or physician? Yes No
Name:

Education - Certification - Skills

Elementary School Name Major Subjects
High School Name Major Subjects
College Name Major Subjects
Other Name
(Business, Vocational, Military) 		Major Subjects
If you are an experienced operator of any business/plant machines or equipment, please list:

Health

Would you take a physical examination (including but not limited to urine, blood, or other examination for evidence of drug or other chemical use)? Yes No

References

Give three references, not relatives or former employers.
Name: Phone:
Address:
City:
State:    Zip:   


Name: Phone:
Address:
City:
State:    Zip:   


Name: Phone:
Address:
City:
State:    Zip:   


Affidavit

I authorize Mountain View Hospital and its agents to use this application to investigate general identification information such as residence verification, and applicable information concerning my employment, education, general reputation, character, personal characteristics, and habits, and that such information may be developed through personal interviews with third parties such as family members, neighbors, friends, associates, former employees, and custodians of official records. Only job-related information developed from such a report will be considered in evaluating my employment application or continued employment. I also understand that if a pre-employment (post offer) drug and/or alcohol test is positive, the employment offer may be withdrawn. I agree to complete any required authorization forms for a general, credit or criminal background investigation required by the Employer.

I certify that the answers given by me to the foregoing questions and statements are true and correct without consequential omissions of any kind whatsoever. I agree that the Employer shall not be liable in any respect if my employment is terminated because of falsity of statements, answers or consequential omissions made by me in this questionnaire. I also authorize the companies, schools or persons named above to give any information regarding my employment, character and qualifications. I hereby release said companies, schools, or persons from all liability for any damage for issuing this information. I understand that any misleading or incorrect statements may render this application void, and if employed, would be cause for termination. I also understand that if employed, either the Employer or I may terminate our relationship at will, without notice or for any reason and that this employment application does not constitute an employment contract. If hired, the Employer is hereby authorized to release to any other firm or person with whom I seek employment, any and all information concerning my employment for the Employer.