Registration Clerk #15; PRN

Name *

Application Date*

Address *

Home/Cell Phone *

Email Address*
If you enter an e-mail address in this box, you will receive an e-mail confirmation that your application was received by Davis County Hospital.

Postition(s) applying for: Please specify job title and job # *
What wage do you expect to earn for this position? *
Were you referred by a current DCH employee? If yes, state employee's name *
If Not, state "No" in the box
Please list job-related skills or experiences *
Have you worked for us before? If yes, state date and provide any other name(s) used. *
If Not, state "No" in the box

Will you accept part-time work?*YesNo

Will you accept temporary work?*YesNo

How much notice do you need to give your current employer?

Are you willing to take a physical exam and a drug test upon a conditional offer of employment?*YesNo

Are you either a US citizen or an alien who has the legal right to work in the job for which you are applying?*YesNo

Pursuant to the Immigration Reform and Control Act of 1986, all applicants, upon being made an offer of employment, must produce documents which are specified by the Federal government, establishing their identity and authorization for employment in the United States. These documents must be produced no later than seventy-two (72) hours after commencement of employment. You will also be required to sign a Form I-9 (issued by the Federal government) verifying, under oath, your employment authorization.

Are you an honorably discharged veteran?*YesNo
Are you related by blood, marriage or adoption to any current employee at Davis County Hospital? If yes, list those relatives *
If Not, state "No" in the box

Education

Last High School *

Number of Years Attended *

Diploma or GED Received? *YesNo

Jr. College/College/University

Academic Major

Number of Years Attended*

Diploma Received? YesNo

Tech/Vocational School

Academic Major

Number of Years Attended*

Diploma Received? YesNo

References

Give names of persons not related to you who we may contact to verify your qualifications for the position:

Name & Occupation of reference *

Organization Name, Address & Phone Number *

Name & Occupation of reference *

Organization Name, Address & Phone Number *

Name & Occupation of reference *

Organization Name, Address & Phone Number *

Employment History

Give a complete record of all employment and reasons for periods unemployed during the past fifteen years. Start with the most recent employment.

Most Recent Employers Name *

Employer's Phone Number *

Employer's Address *

Start Date *

Are you currently employed with this employer? *YesNo

End Date if not currently employed with this employer

Position *

Supervisor *

Specific Duties *

Reason for Leaving *

Name of Second Employer *

Employer's Phone Number *

Employer's Address *

Start Date *
If not applicable, please enter the date of 11/30/2019

End Date*
If not applicable, please enter the date of 11/30/2019

Position *

Supervisor *

Specific Duties *

Reason for Leaving *

Name of Third Employer *

Employer's Phone Number *

Employer's Address *

Start Date *
If not applicable, please enter the date of 11/30/2019

End Date*
If not applicable, please enter the date of 11/30/2019

Position *

Supervisor *

Specific Duties *

Reason for Leaving *

Name of Fourth Employer *

Employer's Phone Number *

Employer's Address *

Start Date *
If not applicable, please enter the date of 11/30/2019

End Date*
If not applicable, please enter the date of 11/30/2019

Position *

Supervisor *

Specific Duties *

Reason for Leaving *

May we contact your present employer(s) for a reference? *YesNo

May we contact your past employer(s) for a reference? *YesNo

List Machines/equipment you can use

Professional Licenses, Registrations, and/or Certifications

Date received initial RN License

Date received initial LPN License

Area of Specialization or Major interest

If the position will involve driving for the company, you are required to provide information relating to your driving record. You will be required to allow review of your driving record prior to hire and annually thereafter.

DISCLOSURES
Check the appropriate box next to each statement below. Checking "Yes" may not automatically disqualify you from employment. Non-disclosure of information may be considered falsification of records.
Have you ever been discharged from a job? *YesNo
Do you have a record of founded child or dependent adult abuse? *YesNo
Have you ever been convicted of a crime other than a simple misdemeanor offense relating to motor vehicles and laws of the road under chapter 321 or equivalent provisions in this state or any other state? This includes but is not limited to "guilty pleas, deferred judgments", etc. If you have questions regarding this, please ask Human Resources as we will have to rescind the job offer if a "crime" shows up on the background check and you have checked "No" to this question. Failure to disclose prior convictions may disqualify your application. *YesNo
Have you ever had a professional license subject to suspension or revocation? *YesNo
Have you ever voluntarily relinquished your professional license? *YesNo
Do you have knowledge, or have you ever been notified, of being placed on the OIG Excluded Provider List? (Even if you were at one time on the excluded provider list, and have since been removed.) *YesNo
If you have answered yes to any of these questions, please provide additional details, including dates
Provide all other names or aliases you have ever previously been known by, including but not limited to nicknames, maiden names and other married names.
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Affidavit:

I certify that the answers given by me to the foregoing questions and statements are true and correct without consequential omissions of any kind whatsoever, I agree that my employer shall not be liable in any respect if my employment is terminated because of the falsity of statements, answers or omissions made by me in this questionnaire. I authorize employers, companies, schools or persons named above to give any information regarding my employment, together with any information they may have regarding me whether or not it is in their records. I hereby release said employees, companies, schools or persons from all liability for any damage, both legal and otherwise, for issuing this information. I also understand as a conditional offer of employment I MUST UNDERGO A PHYSICAL EXAMINATION AND SUBMIT TO A DRUG TEST. I WAS PERSONALLY INFORMED OF THAT FACT IN MY FIRST INTERVIEW WITH A REPRESENTATIVE OF THE COMPANY. I HEREBY CONSENT TO A DRUG TEST AND RELEASE AND HOLD DAVIS COUNTY HOSPITAL HARMLESS FROM ANY AND ALL CLAIMS AND CAUSES OF ACTION THAT I HAVE OR MAY HAVE IN CONNECTION WITH THE CONDUCT OF THE DRUG TEST, THE ANALYSIS OF THE TEST SAMPLE, AND THE MAINTENANCE OF THE RESULTS OF THE TEST. In addition, if accepted for employment, I hereby agree to abide by the rules and policies of my employer. (Direct deposit is authorized as the required payroll procedure for employee wage payment.)

I understand that any offers of employment are contingent on successful completion of the post-offer exam and background checks.

Further, I understand that any employment is “at will” and not for a stated period of time and may be terminated with or without cause, at any time, at the option of either myself or my employer. In addition, should my employer be or become subject to the conditions of the Drug-Free Workplace Act of 1988, I agree to abide by such established policies as relates thereto. 11/09/2017
I Agree *
Signature & Date *