APPLICATION FOR EMPLOYMENT
An Equal Opportunity Employer
915 Anderson Drive • Aberdeen, WA 98520(360) 537-5118Fax: (360) 537-5051
Qualied applicants receive consideration for employment without discrimination based on age, color, creed, marital status,national origin, race, sex, or the presence of any sensory, physical, or mental disability, veterans status, or any other basisprohibited by federal, state, or local laws.
Please complete all information requested on this form. Please type or print clearly. If you wish tosupply additional education or work history information, attach a separate sheet. Submitting an application for employmentdoes not guarantee an interview. A resume is optional and
considered a substitute for any section of the application.
_______________________________________________________ _______________________ _____________
Last First Middle Social Security Number Today’s Date
Street City State Zip Home Phone
Are you at least 18 years of age?
How did you hear about this position?
GHCH Employee, name:____________________
Walk In/Job Posting
Have you any relatives employed here?
No If yes, indicate name(s)__________________________Have you been previously employed here?
No Date_________ Under what name________________
Are you a U.S. Citizen or legally authorized to work in the U.S.?
Proof of Identity and eligibility to work will be required if you are hired.
If you read, write or speak a foreign language and would be willing to translate for patients/customers, please listthe languages.Would you be willing to translate for patients/customers?
During normal work hours only
Voluntarily during off duty hoursHave you been debarred, excluded or are otherwise ineligible for participation in Medicare, Medicaid, or othergovernment payor programs?
No If yes, explain fullyWere you ever discharged for cause, dismissed duringprobation or have you resigned under pressure orunfavorable circumstances?
No If yes,
Dismissal from prior employment will not necessarily barapplicant from employment.Have you ever been convicted of a criminal offense orbeen released from prison?
A “yes” answer to this question will not necessarily barapplicant from employment.
Position(s) applied for: (1)__________________________________ (2)__________________________________Available for:
Per Diem/On-Call Date Available__________Shift Available:
Nights Can you rotate shifts?
Are you willing to work weekends?