Physical Therapy Application for Rangely District Hospital Contact Information Human Resources225 Eagle Crest DriveRangely, CO 81648 HR Director: Jodi Dillon Email: jodi.dillon@rdhosp.org HR Assistant: Jeani Lucero Phone: 970-675-5011Fax: 970-675-8602 Please be sure to check qualifications for positions under the job description before applying. First Name (required) Last Name (required) Middle Initial Are you at least 18 years old? (required)-- Yes No Last 4-Digits of Social Security Number (required) Cell Phone or Home Phone Number (required) Present Street Address (required) Present City (required) Present State (required) Present Zip Code (required) E-Mail Address (required) Previous Address Previous City Previous State Previous Zip Code Position You Are Applying For: (required) General Application Nurse Aide Registered Nurse - Full Time Ward Clerk/CNA Companion at Eagle Crest Assisted Living Dietary Housekeeping/Environmental Services Respiratory Therapist Physical Therapist List your preference of position in order. (required) Type of Position: (required) Per Diem Full Time Part Time Pool PRN Temporary Shift: (required) Day Evening Weekend Night Rotation Salary Requirement $ Are You Willing to Travel?-- Yes No Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?-- Yes No If overtime work is required periodically, does this pose a problem for you?-- Yes No Date Available for Work: Are you legally authorized to work in the United States? (required)-- Yes No Have you ever worked at Rangely District Hospital before? (required)-- Yes No If yes, when? Are you related to another facility employee? (required)-- Yes No How did you learn about this position? State Employment Commission Agency Job Listing Current Employee Internet Ad School Job Line Social Media Website Other Are you able to perform the essential job functions of the position for which you are applying for with or without reasonable accommodations? (required)-- Yes No Describe any accommodations that may be necessary. List any professional licenses, registration, or certifications you possess. Include only the last 4 digits of your Driver's License, if applicable. Include Type, State Issued, Expiration Date, and Number. Indicate if any licenses have been revoked, suspended, or placed on probation. Also indicate if you are ineligible to become licensed or certified in you field. Please explain. (required) Educational History High School (City, State) (required) Last Year Attended in High School 9 10 11 12 Graduated/GED-- High School Diploma GED Did not complete. College Last Year Attended in College 1 2 3 4 Degree or Certificate Work History Current or Most Recent Employer From (Month, Year) (required) To (Month, Year) (required) Company (required) Phone Number (required) Immediate Supervisor (required) Address (required) May we contact them? (required)-- Yes No Name While Employed (required) Job Title (required) Type of Position (required) # Hours / Week (required) Nature of Duties (required) Reason for Leaving (required) 2nd Previous From (Month, Year) To (Month, Year) Company Phone Number Immediate Supervisor Address May we contact them?-- Yes No Name While Employed Job Title Type of Position # Hours / Week Nature of Duties Reason for Leaving 3rd Previous From (Month, Year) To (Month, Year) Company Phone Number Immediate Supervisor Address May we contact them?-- Yes No Name While Employed Job Title Type of Position # Hours / Week Nature of Duties Reason for Leaving Professional References (Other than Relatives) Give references who have a good knowledge of your work. Reference 1: Name, Position, Address (City/State), Phone, Number of Years Known (required) Reference 2: Name, Position, Address (City/State), Phone, Number of Years Known (required) Reference 3: Name, Position, Address (City/State), Phone, Number of Years Known (required) Please Review and Acknowledge That You Understand The Following. In making application for employment: * I certify that the information in this application is true and complete for all practical purposes. It may be verified by the facility or any affiliate. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the facility or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse. * I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable. If such an investigative report is made, I understand that I will receive notice that such a report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation. (required)-- Yes No * I UNDERSTAND AND AGREE THAT ANY EMPLOYEE HANDBOOK WHICH I MAY RECEIVE WILL NOT CONSTITUTE AN EMPLOYMENT CONTRACT, BUT WILL BE MERELY A GRATUITOUS STATEMENT OF FACILITY POLICIES. * I understand that the facility reserves the right to require its employees to submit to blood tests or urinalyses for alcohol or drug screens, or to allow inspection of bags (including purses or briefcases) or parcels brought into or taken out of the facility. I understand that refusal to submit to a urinalysis or blood test, when requested to do so, may result in termination of my employment. * Compliance with this facility's Substance Abuse Policy is a condition of employment. This hospital requires that every newly hired employee be free of alcohol or drug abuse. Each offer of employment is contingent upon successfully completing a urinalysis test/screen for alcohol and drugs in accordance with facility policy. Continued employment is also contingent upon compliance with the hospital's Alcohol and Drug Abuse Policy. (required)-- Yes No *I UNDERSTAND AND AGREE THAT IF I AM OFFERED EMPLOYMENT BY THE FACILITY, MY EMPLOYMENT WILL BE FOR NO DEFINITE TERM AND THAT EITHER I, OR THE FACILITY WILL HAVE THE RIGHT TO TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, I ALSO UNDERSTAND THAT THIS STATUS CAN ONLY BE ALTERED BY A WRITTEN CONTRACT OF EMPLOYMENT WHICH IS SPECIFIC AS TO ALL MATERIAL TERMS AND IS SIGNED BY ME AND THE ADMINISTRATOR OF THE FACILITY. Release: I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my licensure status and my licensure history. (required)-- Yes No Please upload your Resume titled "First Name Last Name Resume". Please upload your Work References titled "First Name Last Name Work References". Date (required) There was a problem saving your submission. Please try again later. Please wait while your submission is being saved... Submitting...Submit Thank you, your submission has been received.
