Employment Application

Application for Employment

1. Position applied for (1): Select One (Required) Acute Services Advanced Practice Provider (APP) Ambulance Drivers (PRN) CardioPulmonary Rehab RN (PRN) Child Care Provider Child Care Provider - PRN Clinic CMA PRN Clinic LPN PRN CNA - $3,000 Sign-On Bonus CNA - Night Shift - $3,000 Sign-on Bonus CNA - Weekend Package Days - $3,000 Sign-on Bonus CNA PRN ED Advanced Care Provider EMT or Paramedic Housekeeping - PRN Maintenance Worker Paramedic or RN Exception Physician PRN Registered Nurse or LPN Radiological Technologist - PRN Receptionist - Primary Location - Birmingham Receptionist - Primary Location - Keosauqua Receptionist - PRN Respiratory Therapist PRN RN Emergency Department PRN RN Nights - $3,000 sign-on bonus Support Services Technician/EVS Lead Therapist - Senior Life Solutions Unit Clerk/CNA
2. Position applied for (2): Select One (Optional) Acute Services Advanced Practice Provider (APP) Ambulance Drivers (PRN) CardioPulmonary Rehab RN (PRN) Child Care Provider Child Care Provider - PRN Clinic CMA PRN Clinic LPN PRN CNA - $3,000 Sign-On Bonus CNA - Night Shift - $3,000 Sign-on Bonus CNA - Weekend Package Days - $3,000 Sign-on Bonus CNA PRN ED Advanced Care Provider EMT or Paramedic Housekeeping - PRN Maintenance Worker Paramedic or RN Exception Physician PRN Registered Nurse or LPN Radiological Technologist - PRN Receptionist - Primary Location - Birmingham Receptionist - Primary Location - Keosauqua Receptionist - PRN Respiratory Therapist PRN RN Emergency Department PRN RN Nights - $3,000 sign-on bonus Support Services Technician/EVS Lead Therapist - Senior Life Solutions Unit Clerk/CNA

Van Buren County Hospital does not accept unsolicited applications and applications are only valid for 60 days.

3. Today's Date:
4. Date you can Start:
5. Referral Source: Please Select Newspaper TV Employment Agency Radio Friend VBCH Website Other
If Other, Please List:
6. Were you referred by an employee of VBCH? Please Select Yes No
If yes, by whom:

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Personal Information

7. Last Name:
8. First Name:
9. Middle Name:
10. Address:
11. City
12. State: Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
13. Zip:
14. Email:
15. Home Phone:
16. Other Phone:
17. Availability Please Select Full-time Part-time Temporary
18. Please describe any work schedule limitations:
19. Have you applied for a job with us before? Please Select Yes No
If yes, please provide an approximate application date.
20. Have you been employed by us before? Please Select Yes No
If yes, please include your title(s) and employment date(s).
21. Do you have relatives employed by us? Please Select Yes No
If yes, please list the relatives.
22. Have you ever been convicted of a felony? Please Select Yes 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.

23. Are you a citizen of the United States, or specifically authorized to be employed in the United States? Please Select Yes No

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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

24. May we contact you current employer? Please Select Yes No
25. Employer Name:
26. Address:
27. City:
28. State: Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
29. Zip:
30. Phone:
31. Job Title:
32. Duties:
33. Start Date:
34. End Date:
35. Salary/Bonus:
36. Reason For Leaving:
Add Employer

Employer 2

Employer Name:

Address:

City:

State: Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Phone:

Job Title:

Duties:

Start Date:

End Date:

Salary/Bonus:

Reason For Leaving:

Remove Employer 2 Add Employer

Employer 3

Employer Name:

Address:

City:

State: Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Phone:

Job Title:

Duties:

Start Date:

End Date:

Salary/Bonus:

Reason For Leaving:

Remove Employer 3

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Education and Training

37. Name and Location of High School:
38. Did you Graduate? Please Select Yes No

Please list technical or trade school, college and post-graduate education, if any:

College

39. School/College:
40. Level Completed:
41. Degree:
42. Major Subjects:
Add School/College
School/College:
Level Completed:
Degree:
Major Subjects:
Add School/College
School/College:
Level Completed:
Degree:
Major Subjects:

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Other Skills

43. Describe any computer, tool, equipment or office machine skills and proficiency level:
44. Describe any other special skills or qualifications which may help you in the position applied for:
45. List all licenses or certificates held, including state, license or certificate type, date issued, and license or certificate number:
46. List any relevant professional or business organizations to which you belong (Optional):

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Veteran Status

Are you a veteran of the armed forces of the United States?

Yes, enter Veteran information

If you are a veteran of the armed forces of the United States, please provide the following information:

Military Branch:

Date of Service:

Discharge Date:

Honorable Discharge? Please Select Yes No

NOTE: A less than honorable discharge will not automatically disqualify you from employment.

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References

Please list three personal references, other than prior employers or relatives, whom we can contact.

Reference 1

47. Name:
48. Phone:
49. How long have you known this reference?
50. Occupation:

Reference 2

51. Name:
52. Phone:
53. How long have you known this reference?
54. Occupation:

Reference 3

55. Name:
56. Phone:
57. How long have you known this reference?
58. Occupation:

Optional: Upload Resume

59. Resume
    only PDF files are allowed

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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

60. Signature: Please type your full name to serve as an electronic signature.
61. Today's Date:

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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.

62. Gender: Please Select Male Female Prefer not to disclose
63. Race: Please Select 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
64. 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

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Voluntary Self-Identification of Disability

Form CC-305, OMB Control Number 1250-0005

Why are you being asked to complete this form?

We are a federal contractor or subcontractor. The law requires us to provide equal employment opportunity to qualified people with disabilities. We have a goal of having at least 7% of our workers as people with disabilities. The law says we must measure our progress towards this goal. To do this, we must ask applicants and employees if they have a disability or have ever had one. People can become disabled, so we need to ask this question at least every five years.

Completing this form is voluntary, and we hope that you will choose to do so. Your answer is confidential. No one who makes hiring decisions will see it. Your decision to complete the form and your answer will not harm you in any way. If you want to learn more about the law or this form, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website.

How do you know if you have a disability?

A disability is a condition that substantially limits one or more of your “major life activities.” If you have or have ever had such a condition, you are a person with a disability. Disabilities include but are not limited to:

View List of Disabilities

Disabilities include but are not limited to:

• Alcohol or other substance use disorder (not currently using drugs illegally)
• Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, HIV/AIDS
• Blind or low vision
• Cancer (past or present)
• Cardiovascular or heart disease
• Celiac disease
• Cerebral palsy
• Deaf or serious difficulty hearing
• Diabetes
• Disfigurement, for example, disfigurement caused by burns, wounds, accidents, or congenital disorders
• Epilepsy or other seizure disorder
• Gastrointestinal disorders, for example, Crohn's Disease, irritable bowel syndrome
• Intellectual or developmental disability
• Mental health conditions, for example, depression, bipolar disorder, anxiety disorder, schizophrenia, PTSD
• Missing limbs partially missing limbs
• Mobility impairment, benefiting from the use of a wheelchair, scooter, walker, leg brace(s) and/or other supports
• Nervous system condition, for example, migraine headaches, Parkinson’s disease, multiple sclerosis (MS)
• Neurodivergence, for example, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, dyslexia, dyspraxia, other learning disabilities
• Partial or complete paralysis (any cause)
• Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema
• Short stature (dwarfism)
• Traumatic brain injury
65. Please select one of the below options: Please Select Yes, I have a disability, or have had one in the past No, I do not have a disability and have not had one in the past I do not want to answer

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

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