PMH Medical Center

Employment Application

We are An Equal Opportunity Employer
APPLICATION FOR EMPLOYMENT
Please furnish all information on this form.
Click here to download a printable application (requires Adobe Reader).

Job Posting Select Posting to Apply for:

Personal Data

Last Name*:

First Name*:

Middle Name:

Email Address:

Home Address*:

City*:

State*:

Zip Code*:

Permanent Address (if different from above):

Home Phone*:

Cell Phone:

Background Data

How did you hear about this opening?:

Names of relatives or friends employed here:

Have you previously applied here?: No Yes

If yes, give last date (mm/yyyy):

Have you previously been employed here?: No Yes

If yes, give dates (mm/yyyy - mm/yyyy):

Work Desired and Availability

Position Applied For:

Seconday Preference, if any:

I am willing to work:

Full-Time

Part-Time

On Call

Temporary

Indicate shift(s) you can work:

Days

Evenings

Nights

Will you work weekends?:

Yes

Will you rotate shifts?

No Yes

Date You Can Start:

Professional Registration / Licensure

Type of registration or license:

State:

Number:

Expiration Date:

Type of registration or license:

State:

Number:

Expiration Date:

If you do not have a required registration or license, have you applied for one?: No Yes

If an examination is required, what date are you schedule to take the examination?:

If not licensed in Washington State, have you applied for reciprocity?: No Yes

Do you currently, or have you ever had restrictions on your license?: No Yes

If yes, please explain:

Driver's License (if applicable to the position)

Do you have a valid driver's license?

No Yes

Have you been convicted of or pled guilty to any traffic-related offense within the past five years?

No Yes

If yes, please explain...

Have you had your driver's license suspended or revoked or had your driving privileges modified by a court of law?

No Yes

If yes, please explain...

EducationHigh School/GED

Name & Location:

Diploma or GED?:

No Yes

Colleges or Schools after high school (include any job related education or training in military service)

Name & Location:

Academic Major, Skill or Trade:

Dates Attended:

Did you graduate?:

No Yes

Last or Present Job

Employer:

From (mm/yyyy):

To (mm/yyyy):

Address:

City:

State:

Zip Code:

Your title:

Employment Type:

Full Time

Part Time

On-Call

Specific Duties:

Last Salary:

Supervisor:

Phone:

Reason For Leaving:

Did you work under a different name?

No Yes

If yes, please list

Previous Job (1)

Employer:

From (mm/yyyy):

To (mm/yyyy):

Address:

City:

State:

Zip Code:

Your title:

Employment Type:

Full Time

Part Time

Specific Duties:

Last Salary:

Supervisor:

Phone:

Reason For Leaving:

Did you work under a different name?

No Yes

If yes, please list

Previous Job (2)

Employer:

From (mm/yyyy):

To (mm/yyyy):

Address:

City:

State:

Zip Code:

Your title:

Employment Type:

Full Time

Part Time

Specific Duties:

Last Salary:

Supervisor:

Phone:

Reason For Leaving:

Did you work under a different name?

No Yes

If yes, please list

Resume (Text Version)

Copy and Paste a text version of your resume here.

Resume (File Attach)

Attach a file to your application submission

Security Code

Applicant Certification

I certify that the information set forth in this application for employment is true and complete to the best of my knowledge. I understand that, if employed, falsified statements on the application shall be considered sufficient cause for dismissal. I understand that my employment shall be contingent upon:

Proof of identity and verification for employment in the United States, in accordance with the Immigration Reform and Control Act of 1986;

The checking of references furnished by me;

The results of mandatory pre-employment urine and alcohol drug screening and background checks;

Verification of licensure and certifications. Absent a union contract to the contrary, I understand that my employment is not governed by any written or oral contact and is considered an "at-will" arrangement. This means that I am free, as is the Hospital, to terminate the employment relationship at any time for any reason so long as there is no violation of applicable federal or state law. If I am employed by this facility, I agree to conform to the standards of conduct and performance and the personnel policies of the organization, which standards and policies may be unilaterally amended by this facility from time to time. I understand that PMH Medical Center's Employee handbook does not constitute an employment contract, either implied or expressed.

I understand that my typed name below shall have the same force and effect as my written signature.

I have read and understand the above information, and assert that all information provided by me is true and accurate.*:

Today's Date: 2013-05-19 00:28:31 PDT

Applicant Notice Employment in positions directly responsible for the care, supervision or treatment of children or developmentally disabled persons, and vulnerable adults must make a written disclosure of certain civil adjudications, convictions, records of crimes against persons and (for licensed personnel) disciplinary board final decisions under a law passed by the 1987 Washington State Legislature (RCW 43.43). Background inquiries on these matters may be made to the Washington State Patrol (WSP) and an online background search firm (Intelius). If you are considered, you will be required to sign a release authorizing the background inquiries. Failure to provide signed authorization and completion of a disclosure statement shall prevent employment in these positions. Information contained from the person's disclosure statement, the WSP inquiry, or the Intelius report will not necessarily prevent employment.

Have you been convicted of a criminal offense or been released from prison within the past (7) years?

No Yes

(A 'yes' answer to this question will not necessarily bar the applicant from employment) If yes, please explain fully:

Have you been debarred, excluded or otherwise ineligible for participation in federal health care programs?

No Yes

If yes, explain fully:

Enter your email to receive a copy of this application:

Reference Release Authorization

I am applying for a job at PMH Medical Center which provides health care to the public. I understand that in order for the hospital to make a knowledgeable hiring decision, they must check with prior employers.

I consent to and authorize PMH Medical Center to contact the above named former employer(s), and its agents and employees, to furnish any reference information concerning me, including achievement, wage history, performance, attendance, personal history, disciplinary information and reason for separation of employment, relating to my employment with the former employer. It is expressly understood that any information given is to be used for the purpose of determining my acceptability for employment.

I therefore release all parties or persons connected with any request for information from claims, liability and damages for whatever reasons arising out of furnishing this information.

This release shall remain in effect for the length of my employment and pertain to future release of the above information for employment-related purposes.

I have read and understand the above information, and assert that all information provided by me is true and accurate.*:

Today's Date: 2013-05-19 00:28:31 PDT