Job Application

Select the jobs you would like to apply for:

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

First Name *
Middle Name
Last Name *
Physical Address
Mailing Address *
Primary Phone *
Cell Phone
Email Address *
Positon Type Full Time
Part Time
Per Diem
Temp
Days and Hours Available
How did you hear about the position? *

Personal Information

Have you ever applied or worked at BVCHD/Hospital? * Yes
No
If so, when?
Do you have any friends or relatives working for BVCHD? * Yes
No
If yes, state name(s) and relationship:
If you are under 18 years of age, can you produce a work permit? * Yes
No
If hired, can you present proof of U.S. citizenship or your legal right to work in this country? * Yes
No
Have you ever been involuntarily terminated from employment or asked to resign by an employer? * Yes
No
If yes, please give company names and details:
Have you ever been convicted of a crime other than traffic infractions? * Yes
No
If yes, please explain: (Exclude convictions for marijuana- related offenses for personal use more than two years old; convictions that have been sealed, expunged or legally eradicated, and misdemeanor convictions for which probation was completed and the case was dismissed. A conviction will not automatically disqualify you for employment. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position applied for will be considered.)
Are you able to perform the essential functions of the job for which you are applying, with or without reasonable accommodation? * Yes
No
If No, what can be done to accommodate your limitation?

Education

High School (Include Name, Location, Major Subjects, and Degrees Conferred) *
College or University
Graduate School
Vocational/Military
Are you registered or certified by any professional organization, or do you hold a professional or occupational license in the State of California? * Yes
No
If Yes, please specify:
Registration or License # with Type & Expiration Date:
Do you speak, write or understand any foreign languages? * Yes
No
If Yes, which language(s)?

Employment History

If presently employed, may we contact your employer? * Yes
No

List present and past employment starting with your most recent employer (last 10 years is sufficient). Please complete this section even if attaching a resume.

Name of Employer #1
Address
Telephone #
Supervisors Name
Your Position and Duties
Dates of Employment (from/to)
Reason for Leaving
Salary (starting/ending)
 
Name of Employer #2
Address
Telephone #
Supervisors Name
Your Position and Duties
Dates of Employment (from/to)
Reason for Leaving
Salary (starting/ending)
 
Name of Employer #3
Address
Telephone #
Supervisors Name
Your Position and Duties
Dates of Employment (from/to)
Reason for Leaving
Salary (starting/ending)
 
Name of Employer #4
Address
Telephone #
Supervisors Name
Your Position and Duties
Dates of Employment (from/to)
Reason for Leaving
Salary (starting/ending)
 
In addition to the information already provided, list any volunteer activities, training or other experience that you feel qualifies you for the position for which you have applied. (Omit any experience that reflects your race, color, religion, age, sex, sexual orientation, marital status or disabilities).
Attach your Resume:

I certify that the answers that I have given to the foregoing questions and statements are true and correct without sequential omissions of any kind whatsoever, I agree that Bear Valley Community Healthcare District shall not be liable in any respect if it terminates my employment because of false or incorrect statements or answers or omissions made by me in this application. I understand that any misstatements or omissions of information are grounds for denial of employment, and if hired are grounds for dismissal. I understand that employment is conditioned upon verification of information contained herein, as well as my passing, to Bear Valley Community Healthcare District’s satisfaction, a pre-employment process, including a post-offer pre- employment drug test and job-related physical examination and satisfactory completion of the INS I-9 form. I give Bear Valley Community Healthcare District the right to request and to the listed employers and schools as well as any other persons, schools, companies, credit bureaus, state licensing, law enforcement and other governmental agencies, the right to provide Bear Valley Community Healthcare District [without further notice to me] any and all information about my background, along with any other pertinent information they may have, personal or otherwise, whether or not it is in the records. I release all parties from all liability, and agree not to file any claims, lawsuit, or any other cause of action of any kind against any person or entity arising out of the furnishing, receipt or use of such information. Bear Valley Community Healthcare District may obtain a consumer report as defined under the Fair Credit Reporting Act if you are being considered for positions with certain executive and/or financial and accounting responsibilities. These reports will include information on my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, criminal record, or mode of living, and to use this information for employment purposes. I understand that if the District relies on a consumer report to make an employment decision, I will be notified about my rights in a separate document. I AGREE THAT MY EMPLOYMENT WITH BEAR VALLEY COMMUNITY HEALTHCARE DISTRICT WILL BE AT- WILL. THIS MEANS THAT EITHER BEAR VALLEY COMMUNITY HEALTHCARE DISTRICT OR I MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME FOR ANY REASON AT ALL, WITH OR WITHOUT NOTICE. THIS CLAUSE CANNOT BE AMENDED, CHANGED, ALTERED OR ABOLISHED EXCEPT IN WRITING SIGNED BY THE DISTRICT’S CHIEF EXECUTIVE OFFICER. I ALSO AGREE THAT MY EMPLOYTMENT WILL BE GOVERNED BY THE EMPLOYEE HANDBOOK; THE HUMAN RESOURCES POLICY MANUAL; OR THE APPROPRIATE MEMORANDUM OF UNDERSTANDING, TO THE EXTENT THAT DOCUMENTS ARE CONSISTENT WITH MY EMPLOYMENT AGREEMENT. THESE DOCUMENTS ARE SUBJECT TO CHANGE FROM TIME TO TIME.

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

*