EMPLOYEE APPLICATION

NAME (LAST)

(FIRST)

(MIDDLE)

Position

Date

In considering your application for employment, Weston County Health Services may conduct a detailed and thorough investigation which may include but is not limited to a criminal record check, interviews or inquiries of prior employers, coworkers, acquaintances, relatives or friends.

PERSONAL

LAST NAME

FIRST NAME

MIDDLE NAME

PHYSICAL ADDRESS

CITY

STATE

ZIP CODE

MAILING ADDRESS

CITY

STATE

ZIP CODE

ANY PREVIOUS NAME(S)?

YES NO

IF YES, IDENTIFY ALL OTHER NAMES INCLUDING MAIDEN NAME

POSITION APPLIED FOR:

SALARY DESIRED:

HOW DID YOU LEARN ABOUT THIS POSITION? (NEWSPAPER, INTERNET, FRIEND, IF OTHER - PLEASE LIST)

DO YOU HAVE RELATIVES OR FRIENDS EMPLOYED IN THIS FACILITY?

YES NO

NAME:

DEPT:

RELATIONSHIP:

HAVE YOU EVER BEEN EMPLOYED IN THIS FACILITY?

YES NO

WHEN?

ARE YOU 18 YEARS OF AGE OR OLDER?

YES NO

ARE YOU A CITIZEN OR AN ALIEN LEGALLY AUTHORIZED TO WORK IN THE UNITED STATES?

YES NO

LONG RANGE OCCUPATIONAL GOALS:

HOME TELEPHONE NO.

CELL TELEPHONE NO.

E-MAIL ADDRESS

PREFERRED METHOD OF CONTACT:

CHECK ALL YOU WOULD CONSIDER WORKING:

WEEKENDS

HOLIDAYS

ON CALL

SHIFT AVAILABILITY (Check all that apply)

DAYS

EVENINGS

NIGHTS

WOULD YOU CONSIDER WORKING

FULL TIME

YES NO

PART TIME

YES NO

PRN

YES NO

HAVE YOU EVER BEEN INVOLVED IN THE SUBSTANTIATED ABUSE OR NEGLECT OF CHILDREN OR ADULTS UNDER THE LAWS OF WYOMING OR ANY OTHER STATE OF THE UNITED STATES?

YES NO

IF YES, WHICH STATE(S) AND EXPLAIN:

HAVE YOU BEEN SANCTIONED, CITED, REPORTED, OR EXCLUDED FROM PARTICIPATION IN MEDICARE, MEDICAID OR ANY OTHER HEALTHCARE RELATED LAW OR REGULATION?

YES NO

IF YES, EXPLAIN

If your answer is "yes" to any of the above , you will not be automatically disqualified from employment consideration, except as required by state or federal law. However, not disclosing information will be considered falsification of this document and will disqualify you from employment consideration.

EDUCATION/SKILLS

SCHOOL

HIGH

NAME AND ADDRESS OF SCHOOL

COURSE OF STUDY

DID YOU GRADUATE?

LIST DIPLOMA OR DEGREE

Add new row

OTHER Business College or Special Course: (Include Special Military Training, Post Graduate and Nursing)

AREA(S) OF SPECIALIZATION OR MAJOR INTEREST:

LIST OFFICE SKILLS INCLUDING COMPUTER/SOFTWARE EXPERIENCE:

LIST HEALTH CARE BUSINESS, OR INDUSTRIAL EQUIPMENT OPERATED:

A COPY OF CERTIFICATION OR DEGREE WILL BE REQUIRED AS CONDITION OF EMPLOYMENT.

PROFESSIONAL LICENSES/CERTIFICATIONS:

CURRENTLY LICENSED/CERTIFIED ELIGIBLE FOR LICENSE/CERTIFICATION

TYPE:

STATE:

NO:

EXP. DATE:

HAS YOUR LICENSE OR CERTIFICATION EVER BEEN SUSPENDED, REVOKED OR ON PROBATION?

YES NO

PLEASE ATTACH DOCUMENTS IF NECESSARY

Add file

Please upload a file

PROFESSIONAL LICENSES/CERTIFICATIONS:

CURRENTLY LICENSED/CERTIFIED ELIGIBLE FOR LICENSE/CERTIFICATION

TYPE:

STATE:

NO:

EXP. DATE:

HAS YOUR LICENSE OR CERTIFICATION EVER BEEN SUSPENDED, REVOKED OR ON PROBATION?

YES NO

PLEASE ATTACH DOCUMENTS IF NECESSARY

Add file

Please upload a file

PREVIOUS EXPERIENCE

ALL SECTIONS MUST BE FILLED OUT COMPLETELY!! DO NOT PUT "SEE RESUME"

PROVIDE INFORMATION REGARDING PREVIOUS EMPLOYMENT BEGINNING WITH MOST RECENT EMPLOYER.

JOB TITLE:

FROM:

TO:

SUPERVISOR'S NAME

SALARY:

EMPLOYER NAME:

PHONE:

ADDRESS:

DUTIES:

WHAT FACTORS WERE INVOLVED IN YOUR DECISION TO LOOK FOR EMPLOYMENT ELSEWHERE AND LEAVE THIS POSITION?

MAY WE CONTACT YOUR CURRENT EMPLOYER?

YES NO

If no, give reason

Add new row

Briefly describe relevant duties and skills acquired through military or volunteer service: (Include dates)

PLEASE IDENTIFY AND EXPLAIN ANY GAPS IN EMPLOYMENT LONGER THAN THREE (3) MONTHS

REFERENCES

LIST AT LEAST THREE (3) PROFESSIONAL/WORK/SCHOOL REFERENCES, THAT WILL BE ABLE TO CONFIRM OR ATTEST TO YOUR WORK ETHIC, ATTITUDE, COMMITMENT, LEVEL OF RESPONSIBILITY, PROFESSIONALISM, ETC. RELATIVES OR PERSONAL FRIENDS ARE NOT ACCEPTABLE REFERENCES.:

Add new row

CAREFULLY READ THIS SECTION PRIOR TO PROVIDING SIGNATURE BELOW

I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete. I understand that any false or misleading representations or omissions made on the application during the hiring process may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date.

I understand that employment may be conditioned upon successfully passing a medical examination and that I may be required to satisfactorily complete a drug screening and background checks as condition of employment.

I hereby authorize persons, schools, my current employer (if applicable) and previous employers and other organizations to provide this facility and its affiliates with any requested information regarding my application or suitability for employment, and I completely release all such persons or entities from any and all liability related to the providing or use of such information.

I understand that my employment is at-will which means that I may terminate the employment relationship at any time and for any reason with or without notice, and that the facility has the same right. I understand that no one has the authority to enter into any agreement contrary to the preceding sentence, except for a written agreement signed by an administrative representative of this facility and notarized.

WESTON COUNTY HEALTH SERVICES TERMS AND CONDITIONS OF EMPLOYMENT IMPORTANT NOTICE READ FULLY, INITIAL EACH PARAGRAPH

INITIAL

I understand that, if I am hired by WCHS, my employment. compensation and/or benefits can be terminated with or without cause, and with or without notice, at the option of either WCHS or myself.

INITIAL

I recognize that WCHS may change, depart from. or contradict from any policies or procedures I may receive if hired by WCHS. I understand that no WCHS policy or procedure. including those in the employee handbook should be considered a promise on which I can rely to my detriment.

INITIAL

I understand that no employee, manager, supervisor, officer or board member of WCHS has any authority to enter into any agreement or make any promises for employment for any specific period of time, or make any statements or promises contrary to this document, other than the Administrator.

INITIAL

I understand that any promise or statement by the Administrator which contradicts this document must be in writing and signed by the Administrator to be enforceable.

APPLICANT'S STATEMENT

I hereby give Weston County Health Services the right to make a thorough investigation of my past employment, education and activities, which will include a criminal background check. I release from all liability all persons companies and corporations supplying such information and indemnify Weston County Health Services against any liability which might result from making such investigation. I understand that any false answer or statement or implications made by me on this application or other required documents shall be considered sufficient cause for denial of employment or discharge.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Applicant's Name (please print)

Applicant's Signature

Date

Your information will be encrypted.