Prosser Memorial Hospital

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Application for Employment

We are An Equal Opportunity Employer

INSTRUCTIONS: Please furnish all information requested on this form.

Position(s) Applied For:

Date of Application:

Personal Data

First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Zip:

Phone Number:

E-mail:

If you are under 18 years of age, can you provide required proof of your eligibility to work?

Yes No

Are you a military veteran?

Yes No

If yes, please list under Work Experience.

How did you learn about this position opening?

Ad Friend Other

Have you been previously employed here?

Yes No If yes, give dates:

Have you any relatives employed here?

Yes No

If yes, please indicate name(s) and in what position.

Have you been convicted of a criminal offense or been released from prison within the past ten (10) years?

(A "yes" answer to this question will not necessarily bar the applicant from employment.)

Yes No

If yes, explain fully:

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

Yes No

If yes, explain fully:

Optional

List any foreign language(s) and check the box that best describes your skill level.

Language	Read/Write/Speak	Read/Write	Read/Speak	Read Only	Speak Only

Work Skills

List training and/or experience which may qualify you for the position(s) desired: (mark "T" if you have training in the skill. Mark "E" if you have experience in the skill. Mark "B" if you have both training and experience.)

Business		General		Patient Care
	Typing (W.P.M.)		Floor Care (Manual)		Sterile Technique
	Shorthand (W.P.M.)		Floor Care (Machines)		Vital Signs
	Transcription		Linen Packing		Pre-Op Preps
	Medical Terminology		Autoclave		Isolation Technique
	Bookkeeping		Sterilizer (Steam/Gas)		Catheterization
	Accounting		Dishwasher (Manual)		Coronary Care
	Ten-Key Adding		Dishwasher (Industrial)		Charting
	Calculator		Sewing		Monitor (Type):
	Key Punch		Maintenance (General)		Intensive Care
	Invoicing/Inventory		Maintenance (Craft)		Orthopedic
	Reception		Electrical		Pediatric
	Phone Switchboard		Plumbing		Geriatric
	Insurance Billing		Building		Medical
	Medicare/Medicaid		Electronics		Surgical
	Word Processing		Small Power Tools		Obstetrics
	Computers		Driving		Oncology
	Data Entry		Other		Other
	Other
	Software	Comments:

Work Availability

Full-time

Part-time

Temporary

On-call

If temporary or on-call, indicate when available:

Indicate shift(s) you will work: 1st shift - days 2nd shift - evenings 3rd shift - nights

Will you rotate shifts?

Yes No

Will you work weekends?

Yes No

Indicate days you are available for work:

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Job Performance Ability

Given your knowledge, skills, education and experience, are you able to perform all the essential functions of the position for which you are applying, with or without reasonable accommodation, as set forth in the job description?

Yes No

Education

High School
Name, Location
	Diploma or GED: Yes No
City State
College or Schools after high school (include any job related education or training in military service.
Name, Location	Academic Major, Skill or Trade	Date Attended	Did you graduate?

City State

City State

City State

Work Experience

List most recent employer first. Include at least past five (5) years, and account for any time gaps in your employment history, including any military service.

1. Name of employer

Address:

Your last job title and description:

Dates employed (mo/yr)
From To
Final Salary $ Reason for leaving?

Name of Supervisor:
Phone #
May We contact? Yes No

2. Name of employer

Address:

Your last job title and description:

Dates employed (mo/yr)
From To
Final Salary $ Reason for leaving?

Name of Supervisor:
Phone #
May We contact? Yes No

3. Name of employer

Address:

Your last job title and description:

Dates employed (mo/yr)
From To
Final Salary $ Reason for leaving?