307-746-4491
dpisciotti@wchs-wy.org
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Employment Application Form
Name
First
Last
Position
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Date / Time
Address Field
Address Line 1
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Address Line 2
City
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State
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Zip Code
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Country
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Home Phone
Cell Phone
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Please include any previous names including maiden name:
Position applied for & desired salary
How did you learn about this position? (newspaper, internet, friend, if other – please list)
Please list name of friends or relatives employed in this facility including department and relationship
Have you ever been employed by this facility?
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Yes
No
If so, when & what department:
Are you 18 years of age or older
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Yes
No
Are you a citizen or an alien legally authorized to work in the United States?
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Yes
No
Long range occupational goals:
Would you consider working:
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Full Time
Part Time
PRN
Have you ever been involved in the substantiated abuse or neglect of children or adults under the laws of Wyoming or any other State in the US?
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Yes
No
If yes, which states(s) and explain:
Have you been sanctioned, cited, reported, or excluded from participation in Medicare, Medicaid or any other Healthcare related law or regulation?
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Yes
No
If Yes, please explain:
Name & address of High School
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Did you graduate?
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Yes
No
Name & address of college
Did you graduate?
Yes
No
Name & address of college
Did you graduate?
Yes
No
Other Business College or Special Courses: (Include Special Military Training, Post Graduate & Nursing)
Area(s) of specialization or major interest:
List office skills including computer/software experience:
List Healthcare, Business, or industrial equipment operated:
A COPY OF CERTIFICATION OR DEGREE WILL BE REQUIRED AS A CONDITION OF EMPLOYMENT. Please list Current Professional Licenses/certifications:
Currently Licensed/Certified
Yes
No
Eligible for License/Certification
Yes
No
Type & Number:
State & Expiration Date
Has Your License or Certificate EVER been suspended, revoked or on probation?
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Yes (Please include documents in necessary
No
ALL SECTIONS MUST BE FILLED OUT COMPLETELY!! DO NOT PUT "SEE RESUME". Provide information regarding previous Employment beginning with the most recent employer
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1. Job Title & Supervisors name
What were the dates you started and ended the job?
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What was your salary?
Employer Name:
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Address & Phone number
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Duties:
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What factors were involved in your decision to look for employment elsewhere & leave this position:
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May we contact your current employer?
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Yes
No
If no, please give reason
2. Job Title & Supervisors name
What were the dates you started and ended the job?
What was your salary?
Employer Name:
Address & Phone number
Duties:
What factors were involved in your decision to look for employment elsewhere & leave this position:
3. Job Title & Supervisors name
What were the dates you started and ended the job?
What was your salary?
Employer Name:
Address & Phone number
Duties:
What factors were involved in your decision to look for employment elsewhere & leave this position:
4. Job Title & Supervisors name
What were the dates you started and ended the job?
What was your salary?
Employer Name:
Address & Phone number
Duties:
What factors were involved in your decision to look for employment elsewhere & leave this position:
Briefly describe relevant duties & skills acquired through military or volunteer service: (Include dates)
PLEASE IDENTIFY AND EXPLAIN ANY GAPS IN EMPLOYMENT LONGER THAN THREE (3) MONTHS:
List at least three (3) PROFESSIONAL/WORK/SCHOOL references that will be able to confirm or attest to your work ethic, attitude, commiment, level of responsibility, professionalism. etc. Relatives or personal friends are NOT acceptable references.
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Name and Relationship; Title; Company Name; Contact Telephone
Name and Relationship; Title; Company Name; Contact Telephone
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Name and Relationship; Title; Company Name; Contact Telephone
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Name and Relationship; Title; Company Name; Contact Telephone
Name and Relationship; Title; Company Name; Contact Telephone
I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete. I that any false or misleading representations or omissions made on the application during the hiring process may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date.
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I agree
I understand that employment may be conditioned upon successfully passing a medical examination and that I may be required to satisfactorily complete a drug screening and background checks as condition of employment.
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I agree
I hereby authorize persons, schools, my current employer (if applicable) and previous employers and other organizations to provide this facility and its affiliates with any requested information regarding my application or suitability for employment, and I completely release all such persons or entities from any a nd all liability related to the providing or use of such information.
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I agree
I understand that my employment is at-will which means that I may terminate the employment relationship at any time and for any reason with or witout notice, and that the facility has the same right. I understand that no one has the authority to enter into any agreement contrary to the preceding sentence, except for a written agreement signed by an administrative represenative of this facilty and notorized.
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I agree
Weston County Health Services Terms and Conditions of Employment IMPORTANT NOTICE! Read fully, and check each paragraph
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I understand that, if I am hired by WCHS, my employment, compensation and/or benefits can be terminated with or without cause, and with or without notice, at the option of WCHS or myself.
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I recognize that WCHS may change, depart from, or contradict from any policies or procedures I may receive if hired by WCHS. I understand that no WCHS policy or procedure, including those in the employee handbook should be consicered a promise on which I may rely to my detirment.
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I understand that no employee, manager, supervisor, officer or board member of WCHS has any authority to enter into any agreement or make any promises for employment for any specific period of time, or make any statements or promises contrary to this document, other than the Administrator.
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I understand that any promise or statement by the Administrator with contradicts this document must be in writing and signed by the Administrator to be enforceable.
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I understand that no course of dealing, conduct or statement verbal or written, which contradicts this document can constitute an express or implied contract regarding my employment, and I should not rely on such conduct or statement.
I HEREBY GIVE WESTON COUNTY HEALTH SERVICES THE RIGHT TO MAKE A THOROUGH INVESTIGATION OF MY PAST EMPLOMENT, EDUCATION AND ACTIVITIES, WHICH WILL INCLUDE A CRIMINAL BACKGROUND CHECK. I RELESE FROM ALL LIABILITY ALL PERSONS COMPANIES AND CORPORATIONS SUPPLYING SUCH INFORMATION AND IDEMNIFY WESTON COUNTY HEALTH SERVICES AGAINST ANY LIABILITY WHICH MIGHT RESULT FROM MAKING SUCH INVESTIGATION. I UNDERSTAND THAT NAY FALSE ANSWER OR STATEMENT OR IMPLICATIONS MADE BY ME ON THIS APPLICATION OR OTHER REQUIRED DOCUMENTS SHALL BE CONSIDERED SUFFICIENT CAUSE FO DENIAL OF EMPLOYMENT OR DISCHARGE.
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Applicant's Name and Date
Signature Field
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Clear
