Community People, Quality Health Care

Leading the way in rural medical excellence

Employment Application Form

Thank you for your interest in employment with Curry Health District, where our Mission is to provide healthcare of the highest quality with genuine caring and compassion.

Our applicants receive consideration for employment regardless of color, sex, creed, religion, age, marital status, national origin, the presence of any sensory, mental or physical disability, veteran status, sexual orientation or any other basis protected by federal, state, or local law.

Please complete the form below.  Required fields are marked with *

Personal Information

                      *Last Name                                                      *First Name                                           Middle Initial                             

  Name:

                      Street Address                                                        City                              State               Zip Code

  Home:

  *Preferred Contact Method:  Email  Phone

                                             Message                    Home                      Cell

  Phone Numbers: Email:

  Best time to reach me: 

  Are you 18 years old or younger?  Yes  No     Are you legally authorized to work in the U.S.  Yes   No

Job Information

  Position(s) applying for:   

  Date available for work:       Starting salary desired: 

  Schedule Desired:

Full-Time

 Part-Time  - Hours/Week:   

On-Call

Temporary

  Available to work the following shifts:  Days            Nights          Weekends          Rotating Shifts

  Are you able to perform the essential functions of this position with or without reasonable accommodation?  Yes   No

Job descriptions are available upon request   

  How did you learn about this position?   Internet - Source       Print Ad - Source 

     Job Fair       Employee Referral - Name        Other - Describe

  Have you ever been employed by Curry General Hospital   Brookings Medical Center   Curry Family Medical

  If yes, list dates of employment:  From   to    Last position held

  Have you ever been dismissed or asked to resign from employment within the past 7 years? Yes  No

  If Yes, briefly explain:
 

  Have you ever been convicted of a felony? yes  No

   (A felony conviction does not automatically
    disqualify you from employment)

If yes, please explain:

Education

                                                             Name                                         City/ST                Did you Graduate?  List Diploma/Degree

 High School/GED:        yes  no    

                                                             Name                                         City/ST                Did you Graduate?  List Diploma/Degree       Field of Study

 Name of School:           yes  no         

                                                             Name                                         City/ST                Did you Graduate?  List Diploma/Degree       Field of Study

 Name of School:           yes  no         

                                                             Name                                         City/ST                Did you Graduate?  List Diploma/Degree       Field of Study

 Name of School:           yes  no         

 

Other special education or training: Areas of specialization or interest:

Licensure and Certification

   Type of registration, license or certification                                Agency                                            Number                   Expiration Date

 

   Type of registration, license or certification                                Agency                                            Number                   Expiration Date

 

   Type of registration, license or certification                                Agency                                            Number                   Expiration Date

 

  Has your professional license ever been revoked, suspended or restricted? yes  no

  If yes, briefly explain: 

Work Skills (please check all that apply)

     Business

     Computers

     General

     Patient Care

Multi-line phone system
Accounts payable / receivable
General Bookkeeping
Accounting/Finance
Secretarial/Administrative
Data entry
Typing - WPM
 Other
 Other

MS Word
MS Excel
MS Outlook
PowerPoint
Access
Desktop Publisher
Visio
 Other
 Other

Registration
Insurance Billing
Sterile Processing
Maintenance
Supply Distribution
Medicare/Medicaid
Medical Terminology
 Other
 Other

Charting
Medical/Surgical
Operating Room
Emergency Room
Pediatric
Labor & Delivery
Geriatric
 Other
 Other

Employment History Must be Completed   (Your resume can not be a substitute for completing this section)

          Give complete information for each position held............Show your most recent position first

                                     Name  (Present or most recent)                         Position

  Employer:  

                                                                                                                                                               City, State, Zip

  Address:     

                                                                                                                             Phone Number

  Supervisor:   If currently employed, may we contact? yes  no

                                                     From                         To

  Employment Dates:             Last hourly/salary: 

  Specific Job Duties: 

  Reason For leaving: 

                                     Name  (Present or most recent)                         Position

  Employer:  

                                                                                                                                                               City, State, Zip

  Address:     

                                                                                                                                                                Phone Number

  Supervisor:  

                                                     From                         To

  Employment Dates:             Last hourly/salary: 

  Specific Job Duties: 

  Reason For leaving: 

                                     Name  (Present or most recent)                         Position

  Employer:  

                                                                                                                                                               City, State, Zip

  Address:     

                                                                                                                                                                Phone Number

  Supervisor:  

                                                     From                         To

  Employment Dates:             Last hourly/salary: 

  Specific Job Duties: 

  Reason For leaving: 

                                     Name  (Present or most recent)                         Position

  Employer:  

                                                                                                                                                               City, State, Zip

  Address:     

                                                                                                                                                                Phone Number

  Supervisor:  

                                                     From                         To

  Employment Dates:             Last hourly/salary: 

  Specific Job Duties: 

  Reason For leaving: 

                                     Name  (Present or most recent)                         Position

  Employer:  

                                                                                                                                                               City, State, Zip

  Address:     

                                                                                                                                                                Phone Number

  Supervisor:  

                                                     From                         To

  Employment Dates:             Last hourly/salary: 

  Specific Job Duties: 

  Reason For leaving: 

                                     Name  (Present or most recent)                         Position

  Employer:  

                                                                                                                                                               City, State, Zip

  Address:     

                                                                                                                                                                Phone Number

  Supervisor:  

                                                     From                         To

  Employment Dates:             Last hourly/salary: 

  Specific Job Duties: 

  Reason For leaving: 

Personal / Professional References

                                                                     Name                                                             Position

 Contact:   

                                                         Street Address                                  Suite                    City                     State       Zip

 Office:    

                                                                    Work Phone             Alt Phone               Fax                                    Email

    

                                                                    Name                                                             Position

 Contact:   

                                                          Street Address                                  Suite                    City                     State       Zip

 Office:    

                                                                     Work Phone             Alt Phone               Fax                                    Email

    

                                                                     Name                                                             Position

 Contact:   

                                                        Street Address                                  Suite                    City                     State       Zip

 Office:    

                                                                    Work Phone             Alt Phone               Fax                                    Email

    

*Certification, Understandings and Release

I certify that all statements made by me on this application (and accompanying resume) are true, complete and correct to the best of my knowledge. I understand that any false or misleading representation or omissions may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date.

 

I understand that any offer of employment I receive may be conditioned upon my ability to pass a drug screen and a background investigation. While I have the right to refuse these, I understand that if I do, the District will withdraw its offer of employment.

 

I understand that any employment with the Curry Health District will be considered to be “At Will.” This means that both the District and I have the right to terminate our employment relationship if either of us, for any reason, feels that it is in our best interest to do so. I also understand that no representative of the District has the authority to make promises related to the length of my employment,and that any additional employment agreement must be in writing and signed by the CEO of Curry Health District.

 

I understand that for management to make a careful and knowledgeable hiring decision, they must communicate with my previous employers, academic institutions and/or credentialing agencies. I consent to and authorize Curry Health District to obtain information related to my prior work experience(s), academic performance and professional credentials. I also authorize all persons and institutions mentioned on my employment application to give information relative to possible future employment and release them from any and all liability related to the provision or use of such information.

 

I hereby acknowledge that I have read and understand the above statements and that I agree to the terms, conditions and release detailed above.

*I agree with the above statement:

Attach your Resume

Attach your Resume 

Additional Comments:

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