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 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
2. 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.

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:

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:

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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