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Star Valley Medical Center Employment Application

As an Equal Opportunity Employer, we do not discriminate in employment on the basis of age, gender, race, color, religion, national origin, disability, veteran status or any other classification protected by local, state, and federal laws.  Please omit any references to any organizations or activities that would indicate race, religion, age, gender, sexual orientation, national origin or ancestry, disability, or political persuasion.

Please fill out the form below to submit your employment application. Be sure to enter an email address below if you want to recieve an email confirmation as well as a PDF copy of the completed application.

Contact Information

Last Name First name Middle initial
 
Email Address Home Telephone Work Telephone May we contact you at work?
  
Mailing Address      
 
City State Zip  
 
Position Applied For Salary Requirements How did you learn about us?  

Additional Information

Have you ever been convicted of a felony?      
If So, Explain
Are you 18 Years of age or older?     
Are you legally authorized to work in the united states?     

Education

High School City/State Diploma or Certificate
College(s)
City/State Dates Attended Major or Course
Degree
Graduate School(s)
City/State Dates Attended Major or Course
Degree
Other courses, training, awards, or certificates that may be relevant to the position for which you are applying.

Employment History

Current or Most Recent Employer

May we contact your current employer?   
Name of Employer Telephone Number
Nature of Business
Address City State Zip
Employment Dates   Title of Position Number of People Supervised
From: To:
Name or Title of Immediate Supervisor Starting Salary Final Salary
Reason for Desiring Change or Leaving

Description of Duties

Previous Employer

Name of Employer Telephone Number
Nature of Business
Address City State Zip
Employment Dates   Title of Position Number of People Supervised
From: To:
Name or Title of Immediate Supervisor Starting Salary Final Salary
Reason for Desiring Change or Leaving
Description of Duties

Previous Employer

Name of Employer Telephone Number
Nature of Business
Address City State Zip
Employment Dates   Title of Position Number of People Supervised
From: To:
Name or Title of Immediate Supervisor Starting Salary Final Salary
Reason for Desiring Change or Leaving
Description of Duties

Previous Employer

Name of Employer Telephone Number
Nature of Business
Address City State Zip
Employment Dates   Title of Position Number of People Supervised
From: To:
Name or Title of Immediate Supervisor Starting Salary Final Salary
Reason for Desiring Change or Leaving
Description of Duties

Office Skills

Typing Speed (Words Per Minute)     
Computer software you have used
Word processing software you have used
Other computer skills you have

Additional Information

Do you have any relatives who are currently working for Star Valley Medical Center?  Who?

Professional References

Name Address Phone Number

Attach a copy of your resume

 
       

The information provided in this Employment Application is true, complete, and correct to the best of my knowledge.  I understand that any false or misleading statements or omissions may result in the rejection of this application, or termination should the discovery of such occur after employment.

I understand that nothing in this Employment Application is intended to imply or create an employment relationship or contract for employment.

I further understand that, if hired, my employment is at-will.  This means that I will have the right to terminate my employment at any time, with or without notice, for any reason.  The company, likewise, will have the right to terminate my employment at any time, with or without notice, for any reason.  I also understand that while personnel policies, programs, and procedures may of necessity change from time to time, such at-will status is not subject to change absent a written agreement signed by the company's president or  designated authorized representative.

I understand that consideration for employment in this position is contingent upon the results of a reference and background investigation.  I therefore authorize the company to investigate all statements made on this Employment Application, and to discuss the results of its investigations with the responsible hiring parties.  I further authorize the company to contact my former employer(s) and any listed references or other persons who can verify information, and I give my consent for former employer(s) and other contacted persons to respond to questions pertaining to information on this application.  Further, I release from liability such former employer(s) or other persons contacted by and providing information to the company.

I hereby acknowledge that I have read and understand the statements in the preceding paragraphs.

Please type your full name below as your signature. Be sure to verify all information entered and that the application is complete before clicking the "Submit Application" button below.

Signature Date
   
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