Employment Application | Mount Grant General Hospital

Application

Applicant Information:

First Name

Middle Name

Last Name

Contact Phone Number

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Position(s) Applying For:

Are you legally eligible to work in the US?

Yes

Have you ever been previously employed by Mt. Grant General Hospital?

Yes

If yes, please include: Department, Position Title, Dates of Employment (From - To Mo/Yr), and Reason for Separation

Education:

High School Education:

College Education:

Other Education:

Employment History:

Please provide at least TWO current/previous positions held.

Current/Previous Position

Previous Position

Professional References:

Please provide THREE professional references. Please include a full name, reachable phone number, and preferred email for each reference.

Reference 1:

First Name

Last Name

Phone/Mobile

Reference 2:

First Name

Last Name

Phone/Mobile

Reference 3:

First Name

Last Name

Phone/Mobile

Other Information

Have you ever been disciplined in your employment related to workplace violence?

Yes

If yes, please explain

Have you ever been terminated or asked to resign?

Yes

If yes, please explain

Criminal History Statement

Nevada Revised Statutes 449 requires that employees or independent contractors of an agency to provide personal care services in the home, an agency to provide nursing in the home, a facility for intermediate care, a facility for skilled nursing, a residential facility for groups or a home for individual residential care or, if residential services are provided to children, a medical facility or a facility for treatment of abuse of alcohol or drugs that provide services to children complete this type of statement. These statutes are available online at http://leg.state.nv.us/NRSINRS-449html. I acknowledge, pursuant to Chapter 449 of the NRS and Nevada Bureau of Licensure and Certification requirements, I must answer the following statement. Initialled:

I further understand that in accordance with Chapter 449 of the NRS, if I have been convicted of any of the following, that I cannot be employed or continue to be employment with Mt. Grant General Hospital. Initialled:

Read and mark EACH statement in the appropriate column. Have you ever been convicted of:

	Yes	No
Murder, voluntary manslaughter or mayhem.
Assault or battery with intent to kill or commit sexual assault or mayhem.
Sexual assault, statutory sexual seduction, incest, lewdness or indecent exposure or any other sexually related crime that is punished as a felony (including felony prostitution).
Prostitution, solicitation, lewdness or indecent exposure, or any other sexually related crime that is punished as a misdemeanor, within the immediately preceding 7 years.
A crime involving domestic violence that is punished as a felony.
A crime involving domestic violence that is punished as a misdemeanor, within the immediately preceding 7 years.
Abuse or neglect of child or contributory delinquency.
Any violation of any federal or state law regulating the possession, distribution or use of any controlled substance or any dangerous drug as defined in Chapter 454 of NRS, within the immediately preceding 7 years.
Abuse, neglect, exploitation or isolation of older persons or vulnerable persons, including, without limitation, a violation of any provision of NRS 200.5092 to NRS 200.50995, inclusive, or a law of any jurisdiction that prohibits the same or similar conduct.
A violation of any provision of law relating to the State Plan for Medicaid or a law of any other jurisdiction that prohibits the same or similar conduct, within in immediately preceding 7 years.
A violation of any provision of NRS 422.450 to 422.590, inclusive, statutory provisions relating to Nevada’s State Plan of Medicaid.
A criminal offense under the laws governing Medicaid or Medicare, within the immediately preceding 7 years.
Any offense involving fraud, theft, embezzlement, burglary, robbery, fraudulent conversion or misappropriation of property, within the immediately preceding 7 years.
Any felony involving the use or threatened use of force or violence against the victim or use of a firearm or other deadly weapon.
An attempt or conspiracy to commit any of the offenses listed here in numbers 1 through 14 within the immediately preceding 7 years.

I affirm, through e-signature below, that the statements 1-15 above are true and correct and that intentionally providing incorrect or untruthful information on this form may result in immediate termination from Mt. Grant General Hospital. I authorize the submission of my fingerprints to the Central Repository for Nevada Records of Criminal History for submission to the Federal Bureau of Investigation for its background check report.

Acknowledgments

Please READ ALL of the following statements and initial EACH of the boxes to indicate you have read and
understand each of the statements. If you have any questions, please contact: Hunter Bolanos, Human Resources Department.

All offers of employment and all information regarding compensation and other terms and conditions of employment will be made in writing. Verbal statements may not be relied upon.

This application is the property of Mt. Grant General Hospital and will become part of my personnel file if I am hired.

I authorize Mt. Grant General Hospital to contact any employer or individual that I have listed on my employment application and/or résumé or mentioned during job interviews to obtain from them any relevant information regarding my previous employment, military service, criminal history, characteristics or traits necessary for job performance, or other relevant qualifications for employment and/or continued employment with Mt. Grant General Hospital. In addition, I authorize Mt. Grant General Hospital to conduct a background search which includes criminal history and military history. In addition, if the position for which I am applying requires driving a vehicle, I authorize Mt. Grant General Hospital to conduct a Department of Motor Vehicles (DMV) search. If the position for which I am applying involves contact with minors or with any persons having diminished capacity to care for themselves, a search of government sex offender registries may be conducted. I further authorize Mt. Grant General Hospital to contact any institution and/or licensing authority to verify my possession of education, licenses, and/or certificates which may qualify me for employment.

In exchange for Mt. Grant General Hospital’s consideration of my employment application, and/or any continued employment with Mt. Grant General Hospital, I authorize anyone possessing information to furnish it to Mt. Grant General Hospital upon request, and I release the organizations and all individuals providing the information or acquiring the information, including Mt. Grant General Hospital, from all claims, liability, and damages whatsoever claimed to be related to furnishing, obtaining, or using said information. This release applies to, but is not limited to, claims for defamation, libel, slander, infliction of emotional distress, and interference with current or prospective economic relations.

I further understand this consent will apply during the entire course of my employment with Mt. Grant General Hospital should I obtain such employment. I understand and agree this consent shall remain in affect indefinitely.

I hereby certify that all statements made in this application are true. I understand that any false statement of material facts herein may cause forfeiture on my part of all rights to any employment with Mt. Grant General Hospital. I understand that any misrepresentation, falsification, or material omission of information may result in my failure to receive an offer, or if I have been hired, in my dismissal from employment regardless of length of employment. I understand that neither this document nor any offer of employment from Mt. Grant General Hospital constitutes an employment contract unless a specific contract document to that effect is executed. I agree to undergo any job-related physical examination and drug screening upon conditional offer of employment. I further understand and agree that this paragraph applies to any information supplied by me at a later date as part of this application.

Per NRS 281.060(2), I opt to exercise my rights by voluntary attaching a copy of my DD214. NRS 281.060(2) states preference must be given, if qualifications of applicants are equal: a) first, to a honorably discharged military personnel of the United States who is a citizen of Nevada; and b) second, to other citizens of Nevada.

Additionally, my e-signature below certifies that the information provided is true and correct to the best of my knowledge. (sign and date)

Please state below any other information that would be helpful in determining your qualifications for this position

Are there any further details or information in connection with what you wrote above which you believe should be explained? For example, if you have moved several times or your jobs were of short duration, you should tell us why. You may also include significant accomplishments, previous career highlights, or any other relevant information that is not requested in this employment application. (optional)

Employment Application:

Applicant Information:

Education:

High School Education:

College Education:

Other Education:

Employment History:

Current/Previous Position

Previous Position

Previous Position

Professional References:

Reference 1:

Reference 2:

Reference 3:

Other Information

Criminal History Statement

Acknowledgments

Please state below any other information that would be helpful in determining your qualifications for this position