Select the jobs you would like to apply for:

Fields marked with an asterisk (*) must be filled out before submitting.

Last Name *
First Name *
Middle Name
Other names under which you have been educated or employed
Available To Work * Full Time
Part Time
Per Diem
Temporary
Days
Nights
Address *
Telephone *
Cell phone
E-mail Address
If you are under 18 years of age, can you produce a work permit if hired? * Yes
No
Can you, after employment, submit verification of your legal right to work in the United States? * Yes
No
If employed in the position for which you have applied, would you be in a supervisory, subordinate, or co-worker (i.e. within the same department) relationship to any relative or member of your household? * Yes
No
If yes, please specify

Education

Highest grade completed 9
10
11
12
College or University (Include Name, Location, Major Subjects, and Degrees Conferred)
Graduate School (Include Name, Location, Major Subjects, and Degrees Conferred)
Other – Military, Apprenticeship, vocational (Include Name, Location, Major Subjects, and Degrees Conferred)
Are you registered or certified by any professional job related organization, or do you hold a professional or occupational license in the State of California? Yes
No
If yes, please specify
Registration or License Details (Include Number, Expiration Date, and Type)
Do you hold or have you ever held a certification, professional or occupational license in a state other than California? Yes
No
If yes, which state?
Registration or License Details (Include Number, Expiration Date, and Type)
Languages you read, speak or write, other than English, if relevant to the job in which you are applying (Indicate if you can Speak/Read/Write)
Source of Referral Self
Newspaper
School
State Employment Office
Community Agency
Recruited by the Hospital

Employment History

Name of Employer #1
Address
Telephone Number / Ext
Your Supervisor
What were your principal duties and title?
Started Work (Month/Year)
Left Work (Month/Year)
Salary ($ per hour)
Reason for leaving?
May we contact? Yes
No
 
Name of Employer #2
Address
Telephone Number / Ext
Your Supervisor
What were your principal duties and title?
Started Work (Month/Year)
Left Work (Month/Year)
Salary ($ per hour)
Reason for leaving?
May we contact? Yes
No
 
Name of Employer #3
Address
Telephone Number / Ext
Your Supervisor
What were your principal duties and title?
Started Work (Month/Year)
Left Work (Month/Year)
Salary ($ per hour)
Reason for leaving?
May we contact? Yes
No
 
Name of Employer #4
Address
Telephone Number / Ext
Your Supervisor
What were your principal duties and title?
Started Work (Month/Year)
Left Work (Month/Year)
Salary ($ per hour)
Reason for leaving?
May we contact? Yes
No
 
Name of Employer #5
Address
Telephone Number / Ext
Your Supervisor
What were your principal duties and title?
Started Work (Month/Year)
Left Work (Month/Year)
Salary ($ per hour)
Reason for leaving?
May we contact? Yes
No
 
In addition to the information already provided, list any volunteer activities, training or other experience that you feels qualifies you for the position for which you have applied: You may omit those which may indicate race, age, sex, religion, color, national origin or sexual orientation.

I hereby certify that I have been informed of the duties of the position that I am applying for and that the information of this application is correct and complete to the best of my knowledge. I agree to have any of the statements checked by the Mountains Community Hospital unless I have indicated to the contrary. I understand and agree that, if offered a position, I will be required to take and pass a physical examination including drug testing before I will be allowed to commence work. Further I understand that falsification or omission of any material information on this application may be considered sufficient cause for immediate termination. I agree that, if employed, I will abide by and observe all policies, procedures, rules and regulations established by Mountains Community Hospital and understand that my employment is at will, if hired.

By typing my name I am offering my electronic signature and acknowledge that I understand and agree to all the preceding statements *