Employment Application

Today's Date *

Position Applying for *

Referred by

Last Name *

First Name *

Middle Initial

Street Address *

City *

State *

ZIP *

Phone

Email *

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Are you 18 yrs or older? *YesNoIf hired, you may be required to provide proof of age.

On what date would you be available for work? *

Have you been employed by us before? *YesNo

If so, please give dates

Are you currently employed? *YesNo

If employed, may we contact your employer? *YesNo

Can you perform the essential functions of this position, either with or without reasonable accommodations? *YesNo

Can you meet the attendance requirements of this position? *YesNo

Can you meet all the job requirements of this position? *YesNo

Are you available to work call when necessary? *YesNo

Have you ever applied for work under another name? *YesNo

If yes, what other name (s)

Do you have a current driver's license? *YesNo

If yes, what is your driver's license number?

Any criminal charges pending? *YesNo

Have you been convicted of a DUI? *YesNo

Have you been convicted of a misdemeanor in the past 7 years? *YesNo

Have you, within the past (7) years, served any portion of a criminal sentence or been convicted of any offense that involved any form of violence such as assault, rape, child abuse, child molesting, extortion, blackmail, coercion or any crime with drugs? *YesNo

Have you, within the past (7) years, served any portion of a criminal sentence or been convicted of any offense that involved embezzlement, fraud, stealing, robbery, extortion, blackmail or coercion? *YesNo

Have you ever had a certificate or license revoked or suspended? *YesNo

Have you ever been voluntarily terminated from any job or asked to resign from any job for reasons relating to your behavior or job performance? *YesNo

Educational Institution

Institution

City/State

Diploma/Degree

Major

Employer

Employer Name

Job Title

Street Address

City

State

ZIP

Phone

Supervisor

Dates of Employment

Job Responsibilities

Reason for leaving

Reference

Name *

Phone *

Street Address *

City *

State *

ZIP *

Statement

I certify that answers given herein are true and complete to the best of my knowledge.

I UNDERSTAND THAT:

I am subject to a background investigation as a condition of employment.
False, omitted, or misleading information given in my application or interview(s), or background information results may result in discharge.
Compliance with the Central Montana Medical Center Code of Conduct is a condition of employment.

This application or subsequent employment does not create a contract of employment nor guarantee employment for any definite period of time or number of hours. Any verbal statements or promises about job security made by any person employed in this facility to any other employee or job applicant must be reduced to writing and signed by the CEO of CMMC before becoming effective and binding upon either party.

CMMC reserved the right to modify, revoke, suspend, terminate or change policies and procedures in whole or part at any time. I am required to abide by all rules and regulations of the employer. Confidential information must be kept confidential.

I HAVE READ, UNDERSTAND, AND BY MY SIGNATURE CONSENT TO THESE STATEMENTS.

Name *

Date

Equal Opportunity

Central Montana Medical Center is an equal opportunity employer. We do not discriminate on the basis of race, color, religion, national origin, marital status, age or disability. All applicable state and federal statutes apply to Central Montana Medical Center. It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors.

CMMC has a Tobacco Free Policy enforced in all buildings owned and operated by the facility.

This application for employment will remain active for a limited time. Please ask for details.

BEFORE A CANDIDATE CAN BE CONSIDERED FOR EMPLOYMENT, THE FOLLOWING REQUIREMENTS MUST BE MET.

A properly completed and signed Application.
A copy of license or certification, if required, for the position for which you are applying.
C.N.A.’s must provide a copy of Skills List from formal training and certification

A Driver’s License, and Social Security card or Birth Certificate, Military or other I.D. are required at hire. PPD (TB testing) or verification of current testing is required of all new hires and annually for all employees.

All applicants and employees are subject to Background Investigations.

THANK YOU FOR YOUR INTEREST IN EMPLOYMENT AT CMMC.

Name *

Date

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