Quality Assurance

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Phone*

A valid phone number is required.

Work/Cell

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Email*

A valid email address is required.

Are you legally allowed to work in the United States?*

Yes No

If, noncitizen please indicate visa type and number:

Are you at least 18 years of age?*

Yes No

Have you ever been employed here before?*

Yes No

May we contact you at work?*

Yes No

Date available to start:*

What position(s) do you want to be considered for?*

Years of Experience:*

Who should consider this application?*

Benewah Community Hospital St. Maries Family Medicine

What status are you applying for?*

What shift are you applying for?*

What statuses would you also consider?*

What shifts would you also consider?*

Have you ever been convicted of a misdemeanor or felony offense?*

Yes No

If yes, explain:

Do you have family members working at the Hospital?*

Yes No

Who?

Where did you hear about this position?*

Professional License Registry or Certification?*

Yes No

If yes, please provide #:

Issue Date:

Issue State

Any other Licenses/Certifications:

Renewal Date

Application Consent*

I hereby certify that all of the information provided by me in this application (or any other accompanying or required documents) is correct accurate and complete to the best of my knowledge I understand that the falsification misrepresentation or omission of any facts in said documents will be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery I understand that submission of an application does not guarantee employment I further understand that should an offer of employment be extended Benewah Community Hospital (hereinafter referred to as "BCH") that such employment with BCH is at will for no specified duration and may be terminated by either BCH or myself at any time with or without cause or notice

Pre-Employment Screening Consent*

I understand that none of the documents policies procedures actions statements of BCH or its representatives used during the employment process is deemed a contract of employment real or implied I understand that no representative of BCH except the CEO has the authority to enter into any agreement guaranteeing any conditions of employment or any agreement contrary to the foregoing statements and that any such agreements must be made in writing and signed by the CEO of BCH In consideration for employment with BCH if employed I agree to conform to the rules regulations policies and procedures of BCH at all times and understand that such obedience is a condition of employment I understand that due to the nature of BCH business attendance and punctuality are considered essential requirements of every job at BCH and that poor attendance or tardiness will result in disciplinary action I understand that if my job requires me to drive in the course of my employment I will be required to possess a current and valid driver’s license and maintain a good driving record. I specifically authorize investigation of my driving record with the DMV by Benewah Community Hospital. I understand that if offered a position with BCH I may be required to submit to a pre-employment medical examination COVID-19 and Influenza vaccinations are required BCH will consider accommodations for medical-and religious-based reasons drug screening and background check as a condition of employment BCH may also obtain a consumer report for employment purposes I understand that unsatisfactory results from refusal to cooperate with or any attempt to affect the results of these pre-employments tests and checks will result in withdrawal of any employment offer or termination of employment if already employed COVID-19 vaccination is required and BCH will consider accommodations for medical-and religious-based reasons and you can request additional information about the vaccine requirements from Human Resources

AUTHORIZATION*

I hereby authorize any and all schools former employers references courts and any others who have information about me to provide such information to BCH and/or any of its representatives agents or vendors and I release all parties involved from any and all liability for any and all damage that may result from providing such information. I understand that this application is considered current for six months. If I wish to be considered for employment after this period I must fill out and submit a new application. BY SIGNING/TYPING MY NAME BELOW I ACKNOWLEDGE THAT I HAVE READ UNDERSTOOD AND AGREE TO THE ABOVE STATEMENTS.

Electronic Signature*

Date*

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