An Equal Opportunity Employer

Glacial Ridge Health System is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Applicants requiring reasonable accommodation in the application and/or interview process should notify a representative of the organization.

Please complete all sections.

Date of Application

Jun 19th, 2013

applicant information

* Required field

Name (First, Middle, Last) *
Current Address *
City *
State *
Zip *

E-mail Address
Home / Primary Phone *
Cell Phone
How were you referred to Glacial Ridge Health System?

employment positions

Positions Requested
Please select the type of work you are applying for. Part-time Full-time Temporary (summer/holiday)
Are you able to meet the attendance requirements of this position? Yes No
Driver's License Number (if job related)

Which days/hours are you available. Please select all that apply.

Mon
Tue
Wed
Thu

Fri
Sat
Sun
Can you work rotating shifts? Yes No
Are you available to work overtime? Yes No
Can you work holidays? Yes No
If hired, on what date can you start working?
Salary / Hourly Rate Desired

personal information

Have you ever applied to or worked for Glacial Ridge Health System before? Yes No
Do you have any friends or relatives working for Glacial Ridge Health System? Yes No
If any, state name or relationship
If hired, would you have transportation to and from work? Yes No
Are you over the age of 18? (If under 18, hire is subject to verification of minimum legal age.) Yes No

If hired, would you be able to present evidence of your U.S. citizenship or proof of your legal right to work in the United States? Yes No
Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation? Yes No
If no, describe the functions that cannot be performed
NOTE: Company complies with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional.
Have you ever been convicted of a criminal offense (felony or misdemeanor)? Yes No
If yes, please describe the crime - state nature of the crime(s), when and where convicted and disposition of the case:
NOTE: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.

education, training and experience

High School

Name of School
City
State

Did you graduate? Yes No

Business School, Vocational, or Correspondence School

Name of School
City
State

Did you graduate? Yes No
Type of Degree / Certificate
Field of Study

College or University

Name of School
City
State

Did you graduate? Yes No
Type of Degree / Certificate
Field of Study

Military Service

Military Branch
Rank

Years of Service
Skills/Duties

Additional Information

Do you speak, write or understand any foreign languages? Yes No
If yes, describe which languages(s) and how fluent of a speaker you consider yourself to be.

Do you have any other experience, training, qualifications, or skills which you feel should be brought to our attention, in the case that they make you especially suited for working with us? Yes No
If yes, please explain.

Professional Licenses and/or Certifications

Type
License #
Organization / State Issued
Date

Type
License #
Organization / State Issued
Date

Type
License #
Organization / State Issued
Date

employment history

Please describe past and present employment positions, dating back five years. Please account for all periods of unemployment. Even if you have attached a resume, this section must be completed.

Present or Last Employer

Name of Employer
City
State
Phone
Name of Supervisor

Your Title
Your Duties
Last Salary / Hourly Rate
Reason for Leaving
Date Began (Month/Year)

Date Left (Month/Year)
May we contact this supervisor/employer for references? Yes No

Previous Employer #1

Name of Employer
City
State
Phone
Name of Supervisor

Your Title
Your Duties
Last Salary / Hourly Rate
Reason for Leaving
Date Began (Month/Year)

Date Left (Month/Year)
May we contact this supervisor/employer for references? Yes No

Previous Employer #2

Name of Employer
City
State
Phone
Name of Supervisor

Your Title
Your Duties
Last Salary / Hourly Rate
Reason for Leaving
Date Began (Month/Year)

Date Left (Month/Year)
May we contact this supervisor/employer for references? Yes No

references

Please list below three persons who have knowledge of your work performance within the last four years. Please include professional references only, not personal references.

Reference #1

Name
City
State

Title
Phone
E-mail Address
Number of Years Acquainted

Reference #2

Name
City
State

Title
Phone
E-mail Address
Number of Years Acquainted

Reference #3

Name
City
State

Title
Phone
E-mail Address
Number of Years Acquainted

attachments

File attachments must be in Microsoft Word or PDF format.

Cover Letter

Resume *

Please read the following, before submitting your application.

I certify that I have not purposely withheld any information that might adversely affect my chances for hiring. I attest to the fact that the answers given by me are true and correct to the best of my knowledge and ability. I understand that any omission (including any misstatement) of material fact on this application or on any document used to secure can be grounds for rejection of application or, if I am employed by this company, terms for my immediate expulsion from the company.

I understand that if I am employed, my employment is not definite and can be terminated at any time either with or without prior notice, and by either me or the company.

I permit the company to examine my references, record of employment, education record, and any other information I have provided.

I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such examination or revelation.

This application is current for only 60 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application.