Application

Senior Leadership 2019-Edit
Paper Application

About You

















Are you a U.S. citizen or an alien legally authorized to work in the United States?*
YesNo




Are under 18 years old?*
YesNo



Association with MMC




Do any of your relatives work for Modoc Medical Center?*
YesNo






Have you ever been employed with us before?*
YesNo






Work Needs Preferences




Do you need any accommodations to physically perform the duties of the job for which you are applying?*
YesNo




Are you available to work:
Full TimePart TimeTemporaryWork Shifts



Education/Skills






Have you had any job-related training in the United States military?*
YesNo







Current/Most Recent Employer










May we contact your current employer?*
YesNo


Previous Employer










May we contact your current employer?
YesNo


Professional References




Please list three professional references and their contact information (do not list relatives):









How did you hear about us?
AdvertisementEmployment AgencyFriendRelativeWalk-InOther



Terms & Conditions




In consideration of my employment, I agree to conform to the rules and regulations of this facility. I understand that my employment can be terminated at any time and for any reason at the option of either the facility or myself. I understand that no one has any authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing, except for in a written employment agreement signed by an administrative representative of the facility. I hereby affirm that the information provided on this application is true and that falsifying this document may disqualify me from further consideration for employment and may result in discharge, even if discovered at a later date. In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, disability or any other legally protected group status. Modoc Medical Center is an equal opportunity employer.




Please state if you agree.*
I Agree









CONTACT AMBER MASON, HR DIRECTOR IF YOU NEED TO SUBMIT SUPPORTING DOCUMENTS WITH YOUR APPLICATION AT a.mason@modocmedicalcenter.org