Application for Employment

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Central Montana Medical Center

408 Wendell Avenue, Lewistown, MT 59457
Phone: (406) 535-6212; Fax: (406) 535-4698

Required Field**

Person who told you about this job and was instrumental in your decision to apply for this job:

Position(s) Applying for:

Today's Date:

Available to work:
Days Nights Full-Time Part-Time Shift Work Temporary Relief On-Call

Last Name:**

First Name:**

Middle Initial:

Street Address:		City:
State:		Zip Code:
Telephone:**		Message Number:
Email:**

Are you 18 years or older?
(If hired, you may be required to provide proof of age.)

Yes No

Have you been employed by us before?

Yes No

If yes:

From:
To:

Are you currently employed?

Yes No

May we contact your current employer(s)?

Yes No

On what date would you be available for work?

Can you perform the essential functions of this position, either with or without reasonable accommodation?

Yes No

Can you meet the attendance requirements of this position?

Yes No

Can you meet all the job requirements of this position?

Yes No

Are you available to work call when necessary?

Yes No

Have you ever applied for work under another name?

Yes No

If yes, what other name(s)?

Have you been convicted of a DUI?

Yes No

Have you had a driver's license revoked?

Yes No

Have you been convicted of a misdemeanor in the past 7 years?

Yes No

Have you within the past (7) years served any portion of a criminal sentence or been convicted of any offense that involved any form of violence such as assault, rape, child abuse, child molesting, extortion, blackmail, coercion or any crime which involves drugs?

Yes No

Have you within the past (7) years served any portion of a criminal sentence or been convicted of any offense that involved embezzlement, fraud, stealing, robbery, extortion, blackmail or coercion?

Yes No

Have you ever had a certificate or license revoked or suspended?

Yes No

Have you ever been voluntarily terminated from any job or asked to resign from any job for reasons relating to your behavior or job performance?

Yes No

Any criminal charges pending?

Yes No

IF YOU CHECKED YES TO ANY OF THE ABOVE
YOU MAY BE CONTACTED FOR MORE INFORMATION.

EDUCATION

Check highest year of education completed:

6 7 8 9 10 11 12 13 14 15 16 Master's Doctorate

List high school, junior college, college, technical/trade, military or business schools below:
INSTITUTION NAME	CITY / STATE	DIPLOMA / DEGREE	MAJOR FIELD

Employment History

Employer Name:		Phone:
Street Address:		City:
State:		Zip Code:
Supervisor:		Title:
Dates of Employment: From		To:
Reason for Leaving:

Employer Name:		Phone:
Street Address:		City:
State:		Zip Code:
Supervisor:		Title:
Dates of Employment: From		To:
Reason for Leaving:

Employer Name:		Phone:
Street Address:		City:
State:		Zip Code:
Supervisor:		Title:
Dates of Employment: From		To:
Reason for Leaving:

List any other employers and / or special skills:

References: 3 persons who can provide job related information
Name, Address, and Telephone Number of EACH:

Name:
Phone:
Address:

Name:
Phone:
Address:

Name:
Phone:
Address:

I certify that answers given herein are true and complete to the best of my knowledge.

I UNDERSTAND THAT:

I am subject to a background investigation as a condition of employment.
False, omitted, or misleading information given in my application or interview(s), or background information results may result in discharge.
Compliance with the Central Montana Medical Center Code of Conduct is a condition of employment.
This application or subsequent employment does not create a contract of employment nor guarantee employment for any definite period of time or number of hours. Any verbal statements or promises about job security made by any person employed in this facility to any other employee or job applicant must be reduced to writing and signed by the CEO of CMMC before becoming effective and binding upon either party.
CMMC reserved the right to modify, revoke, suspend, terminate or change policies and procedures in whole or part at any time. I am required to abide by all rules and regulations of the employer. Confidential information must be kept confidential.

I HAVE READ, UNDERSTAND, AND BY MY SIGNATURE CONSENT TO THESE STATEMENTS.

Name: Date:

Equal Opportunity

Central Montana Medical Center is an equal opportunity employer. We do not discriminate on the basis of race, color, religion, national origin, marital status, age or disability. All applicable state and federal statutes apply to Central Montana Medical Center. It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors.

CMMC has a Tobacco Free Policy enforced in all buildings owned and operated by the facility.

This application for employment will remain active for a limited time. Please ask for details.

BEFORE A CANDIDATE CAN BE CONSIDERED FOR EMPLOYMENT, THE FOLLOWING REQUIREMENTS MUST BE MET.

1. A properly completed and signed Application.
2. A copy of license or certification, if required, for the position for which you are applying.
3. C.N.A.'s must provide a copy of Skills List from formal training and certification

A Driver's License, and Social Security card or Birth Certificate, Military or other I.D. are required at hire. PPD (TB testing) or verification of current testing is required of all new hires and annually for all employees.

All applicants and employees are subject to Background Investigations.

THANK YOU FOR YOUR INTEREST IN EMPLOYMENT AT CMMC.

Name: Date:

Central Montana Medical Center, 408 Wendell Ave, Lewistown, MT 59457 ~ (406) 535-7711