Application - Community Hospital Of Anaconda

Name

First

Middle

Last

Are You At Least 18 Years Old?

Last 4-digits of Social Security Number

Cell Phone Or Home Phone

Present Address

City

State/Province

Zip/Postal

Previous Address

City

State/Province

Zip/Postal

Email Address

Current Open Position(s) for Which You Are Applying Current Open Position(s) for Which You Are Applying

Type of Position

Shift

Salary Requirement $

Are You Willing To Travel?

Are You Willing To Relocate?

Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?

If overtime work is required periodically, does this pose a problem for you?

Date Available For Work

Are You Legally Authorized to Work in the U.S.?

Have you ever worked in this facility?

If yes, what facility?

Are you related to another facility employee?

How did you learn about this position?

Are you able to perform the essential, job related functions of the position for which you are applying with or without reasonable accommodations?

Describe any accommodations necessary

Are you presently charged with any violation of the law?

If yes, give date, place and nature of each such event

Are you currently excluded from participation in any federally funded healthcare program - including Medicare and Medicaid - and are you aware of any potential exclusion from a federally funded health program?

Education History

Type of School

Name of School
City, State

Check Last Year Attended in School

Degree or Certificate

High School

School, City & State

9

10

11

12

Graduated/GED?

Degree

College

School, City & State

1

2

3

4

Graduated?

Degree

College

School, City & State

1

2

3

4

Graduated?

Degree

Graduate School

School, City & State

1

2

3

4

Graduated?

Degree

Other

School, City & State

1

2

3

4

Graduated?

Degree

Other

School, City & State

1

2

3

4

Graduated?

Degree

List any professional licenses, registration or certification you possess (Include only the last 4 digits of your Driver's License, if applicable) Include Type, State Issued, Expiration Date and Number. Indicate if any licenses have been revoked, suspended or placed on probation. Also indicate if you are ineligible to become licensed or certified in your field. Please explain.

Clerical or other skills applicable to the position for which you are applying

TypingTyping

PBX

Proficient in SoftwareProficient in Software

Business machines and/or equipment you can operateBusiness machines and/or equipment you can operate

OtherOther