Applicant Instructions

Thank you for your interest in working at our hospital. We appreciate your application and look forward to the possibility of your joining our team. This sheet is for your information. Please tear it off and keep it for your reference.

Please complete the attached application and authorization for release of information forms. Please print all information so it may be easily read. Be certain all forms are completely filled out and signed. Use the abbreviation of "N/A" if a particular provision or section in the form is not applicable to you. Incomplete applications will not be considered.

Your application will remain in our active files for a period of one year. Should an appropriate opening occur, your application will be reviewed along with others. It is not necessary for you to contact this office regarding any job opening after you have completed your application. If you are among the most qualified applicants for a position an interview will be arranged. Please notify us in writing if your address or telephone number changes.

Employment decisions are made solely on the basis of qualifications to perform the work for which you are applying. Qualifications include education, training and work experience. Credentials and experience will be verified through schools, former employers and licensing/certification agencies, if applicable. As an Equal Opportunity Employer, decisions to hire and promote are made without regard to race, color, creed, national origin, sex, physical or mental handicap (unrelated to ability to do the job), or age (as defined by law).

All applicants may email their application to patsy.smith@dschd.org, fax to (806) 349-9108, or they may be mailed to:

Hereford Regional Medical Center
540 West 15th Street
Hereford, TX 79045
Attn: Human Resources Department.

We appreciate your cooperation.

Application for Employment


Address

Telephone
A conviction will not necessarily be a bar to employment. Each instance and explanation will be considered in relation to the position for which you are applying.


Employment History

Provide the following information for your past three (3) employers, assignments or volunteer activities, starting with the most recent

#1


Address

Hourly rate/Salary
Start
Final
 

#2


Address

Hourly rate/Salary
Start
Final
 

#3


Address

Hourly rate/Salary
Start
Final


Skills and Qualifications

Summarize any training, skills, licenses, and/or certificates that may qualify you as being able to perform job- related functions in the position for which you are applying



Educational Background if job related



References





I UNDERSTAND THAT IF I AM EMPLOYED, ANY MISREPRESENTATION OR MATERIAL OMISSION MADE BY ME ON THIS APPLICATION WILL BE SUFFICIENT CAUSE FOR CANCELLATION OF THIS APPLICATION OR IMMEDIATE DISCHARGE FROM THE EMPLOYER'S SERVICE, WHENEVER IT IS DISCOVERED.

I GIVE THE EMPLOYER THE RJGHT TO CONTACT AND OBTAIN INFORMATION FROM ALL REFERENCES, EMPLOYERS, AND EDUCATIONAL INSTITUTIONS AND TO OTHERWISE VERJFY THE ACCURACY OF THE INFORMTION CONTAINED IN THIS APPLICATION. I HEREBY RELEASE FROM LIABILITY THE EMPLOYER AND ITS REPRESENTATIVES FOR SEEKING, GATHERING AND USING SUCH INFORMATION AND ALL OTIIER PERSONS, CORPORATIONS OR ORGANIZATIONS FOR FURNISHING SUCH INFORMATION.

THE EMPLOYER DOES NOT UNLAWFULLY DISCRIMINATE IN EMPLOYMENT AND NO QUESTION ON THIS APPLICATION IS USED FOR THE PURPOSE OF LIMITING OR EXCUSING ANY APPLICANT FROM CONSIDERATION FOR EMPLOYMENT ON A BASIS PROHIBITED BY LOCAL, STATE OR FEDERAL LAW,

THIS APPLICATION IS CURRENT FOR ONLY 60 DAYS. AT THE CONCLUSION OF THIS TIME, IF I HAVE NOT HEARD FROM THE EMPLOYER AND STILL WISH TO BE CONSIDERED FOR EMPLOYMENT, IT WILL BE NECESSARY TO FILL OUT A NEW APPLICATION.

IF I AM HIRED, I UNDERSTAND THAT I AM FREE TO RESIGN AT ANY TIME, WITH OR WITHOUT CAUSE AND WITHOUT PRIOR NOTICE, AND THE EMPLOYER RESERVES THE SAME RIGHT TO TERMINATE MY EMPLOYMENT AT ANY TIME, WITH OR WITHOUT CAUSE AND WITHOUT PRIOR NOTICE, EXCEPT AS MAY BE REQUIRED BY LAW. THIS APPLICATION DOES NOT CONSTITUTE AN AGREEMENT OR CONTRACT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OR DEFINITE DURATION. I UNDERSTAND THAT NO REPRESENTATIVE OF THE EMPLOYER, OTHER THAN AN AUTHORIZED OFFICER, HAS THE AUTHORITY TO MAKE ANY ASSURANCES TO THE CONTRARY. I FURTHER UNDERSTAND THAT ANY SUCH ASSURANCES MUST BE IN WRITING AND SIGNED BY AN AUTHORIZED OFFICER.

I UNDERSTAND IT IS THIS COMPANY'S POLICY NOT TO REFUSE TO HIRE A QUALIFIED INDIVIDUAL WITH A DISABILITY BECAUSE OF THAT PERSON'S NEED FOR A REASONABLE ACCOMMODATION AS REQUIRED BY THE ADA.

I ALSO UNDERSTAND THAT IF I AM HIRED, I WILL BE REQUIRED TO PROVIDE PROOF OF IDENTITY AND LEGAL WORK AUTHORIZATION.



I REPRESENT AND WARRANT THAT I HAVE READ AND FULLY UNDERSTAND THE FOREGOING AND SEEK EMPLOYMENT UNDER THESE CONDITIONS.


AUTHORIZATION RELEASE FORM

As an applicant for a position with HEREFORD REGIONAL MEDICAL CENTER, I have been requested to furnish information for use in determining my qualifications. In this connection, I do hereby authorize the release and full disclosure of any information that you may have concerning my employment with your company.

I authorize you to release such employment information to those employees and agents of HEREFORD REGIONAL MEDICAL CENTER who require such information in order to make a decision with respect to any matter pertaining to my status as an employee.

I hereby release: (company)

, its employees and anyone acting on company behalf from any and all claims, liability and/or damage of any nature which may result from furnishing the information requested, including, but not limited to, claims of negligence.

A photocopy of this release will be valid as an original even though the photocopy does not contain an original writing of my signature.

This release will expire one (1) year after the date signed,



SUPPLEMENTAL DATA



Have you ever been convicted of, pled guilty or no contest, or received probation, deferred adjudication or pretrial diversion for any criminal offense other than a minor traffic violation?



HOME ADDRESSES FOR PAST 7 YEARS









DISCLOSURE AND AUTHORIZATION REGARDING BACKGROUND INVESTIGATION FOR EMPLOYMENT PURPOSES

Disclosure

Hereford Regional Med Center (the "Company") may request from a consumer reporting agency and for employment-related purposes, a "consumer report(s)" (commonly known as "background reports") containing background information about you in connection with your employment, or application for employment, or engagement for services (including independent contractor or volunteer assignments, as applicable). HireRight, LLC ("HireRight") will prepare or assemble the background reports for the Company. HireRight is located and can be contacted at 3349 Michelson Drive, Suite 150, Irvine, CA 92612, (800) 400-2761, www.hireright.com.

The background report(s) may contain information concerning your character, general reputation, personal characteristics1 mode of living, or credit standing. The types of background information that may be obtained include1 but are not limited to: criminal history; litigation history; motor vehicle record and accident history; social security number verification; address and alias history; credit history; verification of your education, employment and earnings history; professional licensing, credential and certification checks; drug/alcohol testing results and history; military service; and other information.


Authorization

I hereby authorize Company to obtain the consumer reports described above about me.



HEREFORD REGIONAL MEDICAL CENTER
PRE- EMPLOYMENT TESTING AUTHORIZATION


Any individual seeking employment with Deaf Smith hospital District (dba) Hereford Regional Medical Center shall submit to a urinalysis drug test. Testing will be conducted by a certified laboratory/testing service selected by HRMC. I hereby authorize this specimen for the presence of Alcohol, Amphetamines, opiates, cocaine, Barbiturates, and Benzodiazepines. I understand that the test results will be only released to HRMC for consideration of employment. Positive test results or refusal to sign this consent from and participate in pre- employment drug testing shall be grounds for denial of employment. I also understand that I must provide immunization, and receive instructions from the Employee Health Nurse before receiving clearance for employment.