Employment Application

Employment Application
Wind River Family & Community Health Care Human Resources Department P.O. Box 1310, Riverton WY 82501 Phone 307-856-9281 Email: :human.resources@windrivercares.com

Instructions: All sections of this application must be filled out completely, including the names, addresses and phone numbers of your most recent employers. Attach supporting documents, including: Tribal enrollment, honorable discharge (DD214), educational attainment (degrees conferred, transcripts, etc, professional certification, license, 5-year Motor Vehicle record and other relevant documents to verify your job qualifications and your eligibility for preference.
Date*

MonthDayYear
Date
Name (First)*
Name (Last)*
Mailing Address*
Telephone #*
Message #
Email
example@example.com
Driver License #
Class
Endorsement
State Issued
Expiration Date

MonthDayYear
Date
5 Year Motor Vehicle Records Attached?

YesNo
For Indian preference, please submit a Certificate of Tribal enrollment or a copy of Tribal ID:
Are you an enrolled member of the Northern Arapaho Tribe

YesNo
If YES Enrollment #
If no state nationality or Tribal Affiliation
EMPLOYMENT DESIRED:

PermanentPart-time/TemporarySeasonalOther
Position Applied for #1*
Position Applied for #2
Position Applied for #3
Position Applied for #4
If the application is still active submit a separate letter of interest for each Position you wish to be considered for.
Salary Desired
Date Available*

MonthDayYear
Date
Have you ever been employed here before?

NoYes
Start date
End date
Are you employed now

YesNo
May we contact your employer

YesNo
Referral Source
Do you have an immediate family member working for Wind River Family & Community Health Care?

YesNo
Names
Relationship(s)
Program Name(s)
EDUCATION / TRAINING
Trade/Business or other College
High school or GED (Name and location of school)*
Date (Start)

MonthDayYear
Date
Date (Finished)

MonthDayYear
Date
Did you graduate?

YesNo
Degree or Diploma
Field of study (Major/Minor)
College (Name and location of school)
Date (Start)

MonthDayYear
Date
Date (Finished)

MonthDayYear
Date
Did you graduate?

YesNo
Degree or Diploma
Field of study (Major/Minor)
Trade/Business or other College (Name and location of school)
Date (Start)

MonthDayYear
Date
Date (Finished)

MonthDayYear
Date
Type a question

YesNo
Degree or Diploma
Field of study (Major/Minor)
Indicate License; Certification; Professional Credentials:
Subjects of Special Studies
Specify Skills
Clerical skills: Typing Speed
Computer Experience
EMPLOYMENT HISTORY: Please do not indicate "See Resume" on the work performed and list your current employer employer first, additional work performed may be added on a separate sheet if needed
Employer Name and Mailing Address*
Job Title
Supervisor Name
Supervisor Phone #
Reason for Leaving
Dates (Started)

MonthDayYear
Date
Date (Ended)

MonthDayYear
Date
Starting Pay
Final Pay
Work Performed
Employer Name and Mailing Address
Job Title
Supervisor Name
Supervisor Phone #
Reason for Leaving
Date (Started)

MonthDayYear
Date
Date (Ended)

MonthDayYear
Date
Starting Pay
Final Pay
Work Performed
Employer Name and Mailing Address
Job Title
Supervisor Name
Supervisor Phone #
Reason for Leaving
Date (Started)

MonthDayYear
Date
Date (Ended)

MonthDayYear
Date
Starting Pay
Final Pay
Work Performed
Employer Name and Mailing Address
Job Title
Supervisor Name
Supervisor Phone #
Reason for Leaving
Date (Started)

MonthDayYear
Date
Date (Ended)

MonthDayYear
Date
Starting Pay
Final Pay
Work Performed
MILITARY (DD214 required, if claiming veteran preference)
Service Branch
Date Entered

MonthDayYear
Date
Date Discharged

MonthDayYear
Date
Rank Attained
Specialty
Special Training
Type of Discharge
REFERENCES: List three (3) person who are not related to you and who have definite knowledge of your qualifications for the positions you are applying for. Do not repeat name of supervisors listed under work history.
Name*
Address
Business/Title
Phone*
Name*
Address
Business/Title
Phone*
Name*
Address
Business/Title
Phone*
State additional comments you feel may be helpful in considering your application
AUTHORIZATION TO RELEASE INFORMATION AND CERTIFICATION OF ACCURACY
Authorization is hereby given to Wind River Family & Community Health Care to conduct reference and background checks. I also authorize and release every person, firm, previous and current employers, schools, and any other organizations and the Northern Arapaho Tribe, from any and all liability whatsoever resulting from the release of this information. In the event of my employment with the Wind River Family & Community Health Care, I will comply with all rules, regulations, and policies set forth in the Tribal Personnel Manual, and Management Systems. I, hereby, certify that the statements made on this application and any documents submitted in support of this application, including but not limited to any resume, transcripts, etc., are true and correct. I understand that misrepresentation or omission of facts in this application or on any of the documents submitted in support of this application shall be cause for rejection of the application or separation from Wind River Family & Community Health Care.
Signature*

Clear
Date*

MonthDayYear
Date
WIND RIVER FAMILY & COMMUNITY HEALTH CARE PRE-EMPLOYMENT BACKGROUND INVESTIGATION AUTHORIZATION
Wind River Family & Community Health Care requires that a criminal investigation be conducted for applicants who qualify to fill certain positions within the organization. An investigation will be conducted of all information listed on this form. Certain positions may also require that applicants provide their fingerprints with the Human Resource Department. If any of the following needs further explanation, please use a separate sheet of paper.
First*
Middle*
Last*
Maiden
Aliases, other last names used, etc.
Other Names Used: (Aliases, Other last names, etc.)
Telephone #*
Address*
City
State
Zip
Date of birth*
Place of Birth (City, Town)
State
Social Security #*
Sex

MaleFemale
Race (Ethnicity)
Drivers License #
Current:

YesNo
State it was issued
Exp Date

MonthDayYear
Date
Other States You Have Held a Driver License:
Date

MonthDayYear
Date
City
State
Date

MonthDayYear
Date
City
State
Previous Residences: (Go back 10 years)
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState

Postal / Zip Code
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState

Postal / Zip Code
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState

Postal / Zip Code
List any times you were arrested or charged with any violation, including Traffic, but exclude Parking:
Date

MonthDayYear
Date
Place
Charge / Results
Date

MonthDayYear
Date
Place
Charge / Results
Date

MonthDayYear
Date
Place
Charge Results
Are you aware of any information about yourself, which might tend to reflect unfavorably on your reputation, morals, character or ability as a perspective employee of Wind River Family & Community Health Care? Yes or No. If yes, please explain.
Authorization is hereby given to Wind River Family & Community Health Care to request any information and/or to conduct abackground and reference check. I hereby certify that the statements and any documents submitted are true and correct tothe best of my knowledge. I understand that if I falsify statements contained herein, I may not be considered for employment.
Signature of Applicant*

Clear
Date*

MonthDayYear
Date
Please upload any relevant attachments here

Cancelof
This application will retire one (1) year from the date submitted.
Should be Empty:

Employment Application

EDUCATION / TRAINING

AUTHORIZATION TO RELEASE INFORMATION AND CERTIFICATION OF ACCURACY

WIND RIVER FAMILY & COMMUNITY HEALTH CARE PRE-EMPLOYMENT BACKGROUND INVESTIGATION AUTHORIZATION