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 in the Work Experience section below.

Have you any relatives employed here?

Have you been previously employed here?

Have you ever been convicted, entered a plea of guilty, nolo contendere or a plea of similar effect, or had prosecution or sentence deferred or suspected, in connection with:

a) The possession, use, or distribution of controlled substances or legend drugs?

b) A charge of a sex offense?

c) Traffic charges other than civil traffic infractions?

d) Any other crime?

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

For the following 3, please indicate areas of experience related to the job for which you are applying.

Hold down the 'Ctrl' key to make multiple selections.

LIST TRAINING AND/OR EXPERIENCE WHICH MAY QUALIFY YOU FOR THE POSITION(S) DESIRED:

Indicate shift(s) you will work.  Hold down the 'Ctrl' key to make multiple selections.

Indicate days you are available for work.  Hold down the 'Ctrl' key to make multiple selections.

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

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

Do you now have or do you anticipate having any activities, commitments or responsibilities that may prevent you from meeting your work attendance requirements?

If you do not have a required registration or license, have you applied for one?

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?

PLEASE READ THE FOLLOWING BEFORE SIGNING

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

I understand that my employment shall be contingent upon proof of identify 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 furnished 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 arises out of furnishing such job related information.

Regardless of personal preference, I understand that I must be prepared to rotate to less desirable shifts, should the need of the hospital require. I also understand that I will be on a 90-day introductory period from the date of hire, unless extended by my Supervisor.

DRUG TEST CONSENT

Tri-State Memorial Hospital maintains a drug free workplace. As part of the hiring process, we administer pre-employment drug tests. I understand that upon being offered a position at Tri-State Memorial Hospital, I will be required to complete a drug test.

As an equal opportunity employer, we hire without consideration to race, religion, creed, color, national origin, age, gender, sexual orientation, marital status, veteran status or disability. We invite you to complete the optional self-identification fields below used for compliance with government regulations and record-keeping guidelines.