Application

First Name

Last name

Your email

Phone

Address

City

State

ZIP

Position Desired

Are you a U.S. citizen, permanent resident, or a foreign national with authorization to work in the United States?YesNo

Are you under 18 years old?YesNo

Association With Modoc Medical Center

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

If so, please provide their full name and your relationship

Have you ever been employed with Modoc Medical Center before?YesNo

If so, give dates and full name used

Were you referred by a current MMC employee?YesNo

If yes, please provide employees name

WORK NEEDS PREFERENCES

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

What shifts are you available to work?Full TimePart TimeTemporaryWork Shifts

EDUCATION/SKILLS

Please enter the name and address of the High School you attended, and if a diploma was received.

Please enter the name and address of all Colleges or Universities attended, course of study, and any degrees received (If you have not attended any higher education courses please type None)

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

List any licenses and/or certifications that you have obtained, the state issued in, date of issuance, and license number.

CURRENT/MOST RECENT EMPLOYER

Employer's Name

Employer's Phone

Employer's Address

Your Title

Dates of Employment

Reason for Leaving

May we contact this employer?YesNo

PREVIOUS EMPLOYER

Employer's Name (if none, type N/A)

Employer's Phone

Employer's Address

Your Title

Dates of Employment

Reason for Leaving

May we contact this employer?YesNo

PROFESSIONAL REFERENCES

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

Reference 1

Reference 2

Reference 3

Please share any additional relevant information below:

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 or to make any agreement contrary to the previous, 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 later. 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.