Form
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Position Applied for
How did you hear about this position?
Advertisement
Walk In
Referral
Other (please explain)
Referral (by whom?)
Other (please explain)
Earliest Date of Availability
-
Month
-
Day
Year
Date
What type of employment will you accept?
Full-Time
Part-Time
Temporary
Will you be available for shift work?
Yes
No
Will you be available to work weekends and/or holidays if necessary?
Yes
No
Have you been given a job description or had the requirements of the job explained to you?
Yes
No
Do you understand the job requirements?
Yes
No
Can you perform the essential functions of this job with or without reasonable accommodations?
Yes
No
To qualify for employment, applicants must be at least 18 years of age unless otherwise specified in the job announcement. If offered employment, can you furnish proof of age?
Yes
No
After an offer of employment, can you submit verification of your legal right to work in the United States?
Yes
No
List other names you have used, if any.
Did you graduate from high school or receive a GED certificate?
Yes
No
If you have attended business/technical/vocational school, please list the name of the school here.
Where was the location of the school?
How many hours were earned?
What diploma, degree, or certificate was earned?
What was the major field of study?
If you have attended college, please list the name of the school here?
Where was the location of the school?
How many hours were earned?
What diploma, degree, or certificate was earned?
What was the major field of study?
If you have attended post-secondary college (i.e. Master's Degree, Doctorate Degree, etc.), please list the name of the school here?
Where was the location of the school?
How many hours were earned?
What diploma, degree, or certificate was earned?
What was the major field of study?
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List any current licenses, certifications, or registrations required for the position for which you are applying. Indicate types, state license numbers, and expiration dates.
Answer DL questions only if the position requires a driver's license.
Do you possess a valid driver's license?
Yes
No
What is the license expiration date?
What is the DL class?
What restrictions, if any, exist on the license?
For positions that require typing, I certify that I can type at a speed of ________ words per minute.
In addition to English, list any other language abilities you possess.
Verbal fluency in:
Written fluency in:
List any special skills you possess and/or equipment or office machines you can operate.
Other Information
Have you ever been convicted of, pled guilty or nolo contendre to, or been granted deferred adjudication for a felony, misdemeanor (excluding juvenile adjudication), or any lesser crime other than a minor traffic infraction?
Yes
No
Do you have any pending court charges that have not been adjudicated?
Yes
No
If you have answered yes to either question, list all such offenses and provide date, name of court, and disposition (if any). You may omit any minor traffic violations for which you paid a fine of $50 or less. Omission of information may be considered cause for disqualification from the employment pre-screening process or result in termination of employment.
Have you ever been disciplined in your employment related to workplace violence?
Yes
No
If yes, please explain.
Do you presently use illegal drugs?
Yes
No
Have you ever been employed by Pershing General Hospital?
Yes
No
If you have previously been employed by PGH, please provide the following information.
Department
Position Title
Dates of Employment (Month & Year)
Reason for Separation
Are you related to anyone who is currently employed by Pershing General Hospital?
Yes
No
If you are related to anyone who is currently employed by PGH, please provide the following information.
Related Person's Name
Department
What is your relationship to the PGH employee?
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Next
May we contact all employers listed?
Yes
No
Current Employer
Current Position
Address
From (Mo/Year)
To (Mo/Year)
City
State
ZIP
Employment Status
Full-Time
Part-Time
Supervisor's Name/Title
Phone Number
Please enter a valid phone number.
Related Duties
Reason for Leaving
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Please list any significant accomplishments, previous career highlights, or any other relevant information that is not requested in this employment application.
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Acknowledgments
Please read ALL of the following statements and type your initials on each of the statements to indicate that you have read and understand each of the statements. If you have any questions, please contact Human Resources at 775-273-2621 ext. 1003.
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 Pershing General Hospital and will become a part of my personnel file if I am hired.
I authorize Pershing General Hospital to contact any employer or individual to obtain from them any relevant information regarding my previous employment, military service, criminal history, characteristics or traits necessary for job performance, or other qualifications for employment and/or continued employment with PGH. In addition, I authorize PGH to conduct a background check which includes criminal history and military history. In addition, if the position for which I am applying requires driving a vehicle, I authorize PGH to conduct a DMV search. If the position for which I am applying involves contact with minors or any persons having diminished capacity to care for themselves, a search of government sex offender registries may be conducted. I further authorize PGH to contact any institution and/or licensing authority to verify my possession of education, licensure, and/or certification which may qualify me for employment.
In exchange for Pershing General Hospital's consideration of my employment application and/or any continued employment with PGH, I authorize any person possessing information to provide it to PGH upon request and I release the organization and all individuals providing information or acquiring the information, including PGH, 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 that this consent will apply to the entire course of my employment with Pershing General Hospital should I obtain such employment. I understand and agree that this consent shall remain in effect 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 Pershing 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 the length of employment. I understand that neither this document nor any offer of employment from PGH constitutes an employment contract unless a specific contractual document to that effect is executed. I agree to undergo any job-related drug screening and physical examination upon conditional offer of employment. I understand that PGH is not requesting genetic information from the drug screening or the physical examination and that the person administering the examination should not provide any genetic information to PGH. 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 voluntarily attaching a copy of my DD214. NRS 281.060(2) states preference must be given, if qualifications of applicants are equal: (a) first, to an honorably discharged military personnel of the United States who is a citizen of Nevada and (b) second, to other citizens of Nevada.
My signature below certifies that the information provided is true and correct to the best of my knowledge.
Signature
Clear
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