Position applied for (1):
Select One (Required)
Acute Services Advanced Practice Provider (APP)
Ambulance Drivers (PRN)
CardioPulmonary Rehab RN
CardioPulmonary Rehab RN (PRN)
Child Care Provider - $3,000 Hiring Bonus
Clinic CMA PRN
Clinic LPN PRN
CNA
CNA PRN
EMT/Paramedic
EMT/Paramedic/RN Exception
Food Service Worker
Job Coach
Maintenance Worker
Physician
PRN Registered Nurse or LPN
Receptionist - Primary Location - Birmingham
Receptionist - Primary Location - Keosauqua
Referral Coordinator/LPN or MA
Registered Nurse- Weekend
Respiratory Therapist PRN
RN - Nights
RN - Weekend
RN Emergency Department PRN
RN Nights - $3,000 sign-on bonus
Therapist - Senior Life Solutions
Unit Clerk/CNA
Weekend Night RN
Position applied for (2):
Select One (Optional)
Acute Services Advanced Practice Provider (APP)
Ambulance Drivers (PRN)
CardioPulmonary Rehab RN
CardioPulmonary Rehab RN (PRN)
Child Care Provider - $3,000 Hiring Bonus
Clinic CMA PRN
Clinic LPN PRN
CNA
CNA PRN
EMT/Paramedic
EMT/Paramedic/RN Exception
Food Service Worker
Job Coach
Maintenance Worker
Physician
PRN Registered Nurse or LPN
Receptionist - Primary Location - Birmingham
Receptionist - Primary Location - Keosauqua
Referral Coordinator/LPN or MA
Registered Nurse- Weekend
Respiratory Therapist PRN
RN - Nights
RN - Weekend
RN Emergency Department PRN
RN Nights - $3,000 sign-on bonus
Therapist - Senior Life Solutions
Unit Clerk/CNA
Weekend Night RN
Van Buren County Hospital does not accept unsolicited applications and applications are only valid for 60 days.
Today's Date:
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Were you referred by an employee of VBCH?
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If yes, please provide an approximate application date.
Have you been employed by us before?
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If yes, please include your title(s) and employment date(s).
Do you have relatives employed by us?
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If yes, please list the relatives.
Have you ever been convicted of a felony?
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No
Yes, as follows:
NOTE: A conviction record will not necessarily disqualify an applicant from employment. The circumstances of the
conviction will be considered in relation to the nature and duties of the job applied for.
Are you a citizen of the United States, or specifically authorized to be employed in the United States?
Please Select
Yes
No
Prior Employment
List your last three jobs, beginning with the most recent (you may omit dates for jobs
held for more than five years ago)
Employer 1
May we contact you current employer?
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Employer Name:
Address:
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State:
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Alabama
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Arizona
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California
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Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
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Washington
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Reason For Leaving:
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Education and Training
Name and Location of High School:
Did you Graduate?
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Please list technical or trade school, college and post-graduate education, if any:
College
School/College:
Level Completed:
Degree:
Major Subjects:
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Other Skills
Describe any computer, tool, equipment or office machine skills and proficiency level:
Describe any other special skills or qualifications which may help you in the position applied for:
List all licenses or certificates held, including state, license or certificate type, date issued, and license or certificate number:
List any relevant professional or business organizations to which you belong (Optional):
Veteran Status
Are you a veteran of the armed forces of the United States?
Yes, enter Veteran information
References
Please list three personal references, other than prior employers or relatives, whom we can contact.
Reference 1
Name:
Phone:
How long have you known this reference?
Occupation:
Reference 2
Name:
Phone:
How long have you known this reference?
Occupation:
Reference 3
Name:
Phone:
How long have you known this reference?
Occupation:
Optional: Upload Resume
Resume
only PDF files are allowed
Van Buren County Hospital
By signing below, I certify that the answers and information set out above are true, accurate and complete to the best of my knowledge. I acknowledge that if any answer or information is not true, accurate or complete, I may not be hired, or if hired, I may be discharged. I authorize Van Buren County Hospital to investigate all statements contained in this application for employment and to investigate my character and qualifications. I authorize my prior employers, references, and others with information regarding my work or education history or my character, to provide Van Buren County Hospital with all requested information and references, and to cooperate fully with the investigation of my character and qualifications.
I understand that Van Buren County Hospital does not accept unsolicited applications and that applications are only valid for 60 days.
I understand that this application is not a contract of employment. I also acknowledge that no oral representations have been made, and that no one within Van Buren County Hospital has the authority to make oral contracts of employment. If hired, my employment relationship with Van Buren County Hospital is terminable at-will, with or without cause, by either myself or Van Buren County Hospital.
I also understand that any offer of employment will be conditioned upon my passing a pre-employment physical examination, which may include a drug and/or alcohol test and may include a medical examination by a physician selected by Van Buren County Hospital, to which I hereby consent.
I understand and agree to all of the conditions and statements set forth above, and throughout this application.
Your Signature
Signature:
Please type your full name to serve as an electronic signature.
Today's Date:
Applicant Information
Van Buren County Hospital, is an Affirmative Action/Equal Opportunity Employer and does not discriminate on the basis of race, color, religion, sex, age, national origin, disability, veteran status, or any other classification protected by Federal, state, or local law.
This information will be used strictly for statistical record-keeping purposes and will be kept confidential. Providing—or not providing—the gender/race/ethnic/veteran’s status information on this form will neither impact whether or not you are hired, nor will it affect your employment in any manner if you are hired. If you choose not to self-identify, you must select the declination box below to move forward with the application process. The person(s) making hiring and personnel decisions will not see this form.
If you prefer not to self-identify, select "Prefer not to disclose" in each box below.
Gender:
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Male
Female
Prefer not to disclose
Race:
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Hispanic or Latino
White (Not Hispanic or Latino)
Black or African American (Not Hispanic or Latino)
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
Asian (Not Hispanic or Latino)
American Indian or Alaskan Native (Not Hispanic or Latino)
Two or More Races (Not Hispanic or Latino)
Prefer not to disclose
Veteran's Status:
Please Select
None
Vietnam Era Veteran
Newly Seperated Veteran (discharge or released in the last year)
Special Disabled Veteran
Other Protected Veteran
Prefer not to disclose