Prosser Memorial Hospital

Application for Employment

Position(s) Applied For:

Date of Application:

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

Are you a military veteran?

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:

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?

Optional

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

Read/Write/Speak

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.)

Floor Care (Manual)

Sterile Technique

Floor Care (Machines)

Medical Terminology

Isolation Technique

Sterilizer (Steam/Gas)

Dishwasher (Manual)

Dishwasher (Industrial)

Maintenance (General)

Invoicing/Inventory

Maintenance (Craft)

Phone Switchboard

Insurance Billing

Medicare/Medicaid

Small Power Tools

Work Availability

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?

Will you work weekends?

Indicate days you are available for work:

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

Diploma or GED: Yes No

College or Schools after high school (include any job related education or training in military service.

Academic Major, Skill or Trade

Did you graduate?

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)

Final Salary $

Reason for leaving?

Name of Supervisor:

May We contact? Yes No

2. Name of employer

Address:

Your last job title and description:

Dates employed (mo/yr)

Final Salary $

Reason for leaving?

Name of Supervisor:

May We contact? Yes No

3. Name of employer

Address:

Your last job title and description:

Dates employed (mo/yr)

Final Salary $

Reason for leaving?

Name of Supervisor:

May We contact? Yes No

4. Name of employer

Address:

Your last job title and description:

Dates employed (mo/yr)

Final Salary $

Reason for leaving?

Name of Supervisor:

May We contact? Yes No

Did you work for any of the above employers under a different name?
If so, please type in which one(s) Give previous name:

Do you now have or do you anticipate having any activities, commitments or responsibilities that may prevent you from meeting your work attendance requirements? Yes No

If yes, please explain

Professional Registration/Licensure

Type of Registration or License

Date of Expiration

If you do not have a required registration or license, have you applied for one? Yes No
If an examination is required, what date are you scheduled to take the examination?
If not licensed in Washington State, have you applied for reciprocity? Yes No
Have you ever had a professional registration/license revoked, suspended or restricted? Yes No
If yes, explain fully

I certify 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 this application or failure to furnish all requested information shall be considered sufficient cause for my dismissal.

I understand my employment shall be contingent upon proof of identity and verification of eligibility for employment in the United States in accordance with the Immigration Reform and Control Act of 1986. I further understand that my employment is contingent upon the checking of references furnish by me.

I consent to and authorize this employer and its personnel to request any information concerning my previous employment record as indicated on this Application for Employment. I hereby release all parties and persons connected with any request for information from all claims, liabilities, and damages for whatever reason arising out of furnishing such job related information.

I consent and authorize Prosser Memorial Hospital to check with the Washington State Patrol Crime Records Division for record of convictions of crimes against children or other persons, crimes relating to financial exploitation of a vulnerable adult, and crimes relating to drugs (manufacture, delivery, or possession with intent to manufacture or deliver a controlled substance) as prescribed by RCW 43.43.830 and 43.43.834. I understand that I will be required to complete a written disclosure statement of certain civil adjudications, convictions, records of crimes against persons, and (for licensed personnel) disciplinary board final decisions. The WSP form must also be completed by the applicant. Failure to provide the disclosure statement shall prevent employment in these positions. Information obtained from the person’s disclosure statement or from the WSP inquiry will not necessarily prevent employment.

I further understand that I will be required to complete pre-employment and for-cause drug testing in accordance with Prosser Memorial Hospital's post-offer drug screen policy.

I consent to and authorize PMH and its personnel to request any information concerning my previous employment and other relevant reference records. I hereby release all parties and persons connected with any request for information from all claims, liabilities, and damages for whatever reason arising out of furnishing reference related information.

I have read the minimum requirements for the position for which I am applying, and attest I meet the minimum requirements of the position as posted.

My typed name below shall have the same force and effect as my written signature.

Signature of Applicant: Date:

Prosser Public Hospital District
723 Memorial Street I Prosser, WA 99350 I (509) 786-2222 I Contact Us
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