Apply for MA/CNA - Clinic Float - Nevada Regional Medical Center

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Apply for MA/CNA - Clinic Float

Please fill out the form below and click Submit to submit your application for consideration. Fields with an asterisk (*) are required.

Summary
Title:	MA/CNA - Clinic Float
ID:	1315
Location:	Nevada, Missouri
Department:	Rural Health Clinics
Status:	Full Time
Shift:	Days

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* First Name:
* Last Name:
* Address 1:
Address 2:
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Opt-In Confirmation
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NRMC Health - Custom Application for Employment

PERSONAL INFORMATION

* Are you legally eligible to be employed in the United States? (Proof of identity and eligibility will be required upon employment)

Yes No

* Are you at least 18 years or older? (If no, you may be required to provide authorization to work)

Yes No

* Have you ever worked for this Company before?

Yes No

If Yes, please provide details (Where/When/Job Title)

How did you hear about us?

* Were you referred by a current employee?

Yes No

If yes, please provide name.

* Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?

Yes No

If no, please explain

* Have you ever worked for Nevada Regional Medical Center, Moore Few Care Center or Barone Alzheimer’s Care Center?

Yes No

* Are you related to any current employees?

Yes No

If yes, please explain.

* Have you ever been convicted of a crime?

Yes No

If yes, please explain.

EMPLOYMENT DESIRED

When would you be available to begin work?

Type of employment desired

Full Time Part Time Seasonal

Hourly rate/salary desired

Are you currently employed?

Yes No

If so may we inquire of your present employer?

Yes No

If presently employed, why are you considering leaving?

EDUCATION

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School 1

Name

Location

Did you Graduate?

Yes No

Degree Received

Subjects Studied/Major

School 2

Name

Location

Did you Graduate?

Yes No

Degree Received

Subjects Studied/Major

School 3

Name

Location

Did you Graduate?

Yes No

Degree Received

Subjects Studied/Major

School 4

Name

Location

Did you Graduate?

Yes No

Degree Received

Subjects Studied/Major

School 5

Name

Location

Did you Graduate?

Yes No

Degree Received

Subjects Studied/Major

SKILLS

License or Certification

Number

State issued

Expiration date

License or Certification

Number

State issued

Expiration date

License or Certification

Number

State issued

Expiration date

Do you have a Current/Valid Driver’s License

Yes No

Do you have Proof of insurance

Yes No

EMPLOYMENT HISTORY

Give your full employment record, starting with your current or most recent employment.

Employer 1

Job Title

From

Company Name

Company Address

Company Phone

Supervisor Name

Supervisor Title

May we Contact?

Yes No

Responsibilities

Reason for Leaving

Employer 2

Job Title

From

Company Name

Company Address

Company Phone

Supervisor Name

Supervisor Title

May we Contact?

Yes No

Responsibilities

Reason for Leaving

Employer 3

Job Title

From

Company Name

Company Address

Company Phone

Supervisor Name

Supervisor Title

May we Contact?

Yes No

Responsibilities

Reason for Leaving

Employer 4

Job Title

From

Company Name

Company Address

Company Phone

Supervisor Name

Supervisor Title

May we Contact?

Yes No

Responsibilities

Reason for Leaving

Employer 5

Job Title

From

Company Name

Company Address

Company Phone

Supervisor Name

Supervisor Title

May we Contact?

Yes No

Responsibilities

Reason for Leaving

REFERENCES

Please provide three references (not relatives).

Reference 1

Name

Relationship

Phone Number

Reference 2

Name

Relationship

Phone Number

Reference 3

Name

Relationship

Phone Number

AUTHORIZATION

The facts set forth in this application and any supplemental information are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be considered sufficient cause for immediate discharge. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me. If I am hired, I understand that either the company or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of the company has the authority to make any assurance to the contrary.

I understand that I am required to abide by all rules and regulations of the company.

* Signature (type name)

* Date

NRMC Health - Waiver Release

RELEASE AND AUTHORIZATION

In connection with my Employment Application with Nevada Regional Medical Center and/or its affiliated or subsidiary entities, or as a current employee of Nevada Regional Medical Center, I understand and acknowledge that an investigative background inquiry will be made which will include but may not be limited to, an inquiry into my criminal, driving, and other records and reports. I further understand and acknowledge that these reports will include past employment performance and experience, and reasons for my termination from past employers.

I further understand and acknowledge that as a part of their inquiry, Nevada Regional Medical Center will request appropriate private and governmental agencies to conduct a criminal background check on me and to report the results of that background check to Nevada Regional Medical Center. I understand that an unsatisfactory record will be grounds for unfavorable consideration or dismissal from employment.

I hereby voluntarily and knowingly authorize Nevada Regional Medical Center to engage in the above described inquiries, and further authorize any present employer or supervisor, past employer or supervisor, college, university or other institution of learning, administrator, law enforcement agency, state agency (ie.EDL), federal agency (1e.OIG, GSA), private business, military branch, personal reference, and/or· other persons, to give records or information they may have concerning my criminal history, motor vehicle history, character, and employment records requested by Nevada Regional Medical Center or its subsidiaries.

I further understand that any omission, misrepresentation or falsification of information in response to any question during the application process or during my employment with Nevada Regional Medical Center or its subsidiaries may result in my being refused employment or, if already in the employment of Nevada Regional Medical Center, my immediate termination.

I voluntarily, knowingly and unconditionally release Nevada Regional Medical Center and any person, agency or provider of information to Nevada Regional Medical Center from any and all liability resulting from the furnishing of any information covered by this Release and Authorization. This authorization shall be valid during the preemployment process and throughout any employment with Nevada Regional Medical Center or its subsidiaries.

* First Name

* Middle Name

* Last Name

* Other names known by

* Social Security Number

* Date of Birth

* Sex

* States resided in the past 10 years

* Origin

African American Caucasian Hispanic Asian/Pacific Islander American Indian/Alaskan Native

EMPLOYEE DISQUALIFICATION LIST (Pursuant to §660.317, RSMo)

Are you listed on an Employee Disqualification List (EDL) maintained by the:

* Dept. of Social/Division of Aging?

Yes No

* Division of Family Services

Yes No

* Dept. of Mental Health

Yes No

* Signature

* Date

Equal Opportunity Employment

We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.

Gender:

Female
Male
I Choose Not to Respond

Race/Ethnicity:

	American Indian or Alaska Native (Not Hispanic or Latino) A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment
	Black or African American (Not Hispanic or Latino) A person having origins in any of the Black racial groups of Africa
	Hispanic or Latino A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race
	Asian (Not Hispanic or Latino) A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
	White (Not Hispanic or Latino) A person having origins in any of the original peoples of Europe, North Africa, or the Middle East
	Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
	Two or More Races (Not Hispanic or Latino) All persons who identify with more than one of the above races
	I Choose Not to Respond

Veteran Status: (Please check all that apply)

	Individual with a Disability An individual with a disability is a person who has a physical or mental impairment which substantially limits one or more of such person's major life activities, or who has a record of such impairment.
	Vietnam Era Veteran A person who 1) Served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases; or 2) Was discharged or released from active duty for a service-connected disability if any part of such active duty was performed; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases.
	Disabled Veteran 1) A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or 2) A person who was discharged or released from active duty because of a service-connected disability.
	War/Campaign/Expedition Veteran A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized.
	Armed Forces Service Medal Veteran A veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order No. 12985. To identify the military operations that meet this criterion, check your DD Form 214, Certificate of Release or Discharge from Active Duty.
	Recently Separated Veteran Any veteran during the three-year period beginning on date of such veteran's discharge or release from active duty in the U. S. military, ground, naval or air service.
	I Choose Not to Respond

I agree that this form may be electronically signed and agree that my typed signature is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.

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