Position applied for (1):
Select One (Required)
Acute Services Advanced Care Practitioner (ACP)
Ambulance Drivers (PRN)
Clinic CMA PRN
Clinic CMA, LPN, or RN $3,000 Sign-on Bonus!
Clinic LPN PRN
CNA PRN
ED Advanced Care Provider (PRN)
EMT or Paramedic
EVS/Housekeeping
Mental Health Counselor
Occupational Therapist
Part-Time - Child Care Provider
PRN Registered Nurse or LPN
Registered Nurse
Registered Nurse- Weekend
Respiratory Therapist - $3,000 Sign-on Bonus
RN Emergency Department PRN
Position applied for (2):
Select One (Optional)
Acute Services Advanced Care Practitioner (ACP)
Ambulance Drivers (PRN)
Clinic CMA PRN
Clinic CMA, LPN, or RN $3,000 Sign-on Bonus!
Clinic LPN PRN
CNA PRN
ED Advanced Care Provider (PRN)
EMT or Paramedic
EVS/Housekeeping
Mental Health Counselor
Occupational Therapist
Part-Time - Child Care Provider
PRN Registered Nurse or LPN
Registered Nurse
Registered Nurse- Weekend
Respiratory Therapist - $3,000 Sign-on Bonus
RN Emergency Department PRN
Van Buren County Hospital does not accept unsolicited applications and applications are only valid for 60 days.
Today's Date:
Date you can Start:
Referral Source:
Please Select
Newspaper
TV
Employment Agency
Radio
Friend
VBCH Website
Other
If Other, Please List:
Were you referred by an employee of VBCH?
Please Select
Yes
No
If yes, by whom:
Personal Information
Last Name:
First Name:
Middle 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:
Email:
Home Phone:
Other Phone:
Availability
Please Select
Full-time
Part-time
Temporary
Please describe any work schedule limitations:
Have you applied for a job with us before?
Please Select
Yes
No
If yes, please provide an approximate application date.
Have you been employed by us before?
Please Select
Yes
No
If yes, please include your title(s) and employment date(s).
Do you have relatives employed by us?
Please Select
Yes
No
If yes, please list the relatives.
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.
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?
Please Select
Yes
No
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:
Add Employer
Education and Training
Name and Location of High School:
Did you Graduate?
Please Select
Yes
No
Please list technical or trade school, college and post-graduate education, if any:
College
School/College:
Level Completed:
Degree:
Major Subjects:
Add School/College
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:
Please Select
Male
Female
Prefer not to disclose
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
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
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
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.