Application for Employment

    Bear Lake Memorial Hospital is committed to a policy of non-discrimination and equal employment opportunity.Please complete all sections of the application in full, rather than stating “see resume.” Resumes will not be accepted as a substitute for a completed application. Incomplete applications will not be considered. A specific job title for a currently posted position must be identified. A new application must be submitted for any additional positions for which you would like to be considered. All applicants selected for employment with Bear Lake Memorial Hospital will be required to satisfactorily pass a pre-employment drug screen and criminal background check.

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    Date of application *

    Position for which you are applying *

    Last Name *

    First Name*


    Street Address*




    E Mail Address

    Home Phone*

    Work Phone

    Other Phone

    Classification *
    FT (40 hr/wk)RPT (32 hr/wk)Occasional (<30 hr/wk)PRN (as needed)Temp (<6 months)

    Work Schedule / Shift: What work schedule/shift are you willing to work?*

    Are you willing to work weekends?

    Date available to start work:

    Please mark the days of the week you are available and willing to work *

    Current Salary: $

    Minimum Salary Requirement: $

    How did you hear about this position?*
    Walk-inInternetJob FairNewspaperRadioEmployment AgencyPast EmploymentStudent Work ExperienceJob Bulletin BoardEmployee Referral

    Employee's Name:


    Have you ever been convicted of a felony or a misdemeanor (including withheld judgments or other plea agreements), or have you ever plead no contest to any criminal charges?*
    YesNoNot Sure

    If yes or not sure, please provide date, city, state and an explanation:

    Are you or have you ever been debarred from working in a federally funded program, i.e., Medicaid, Medicare?*

    Can you perform the functions of the job for which you are applying, either with or without a reasonable accommodation?*

    Do you have any relatives employed by Bear Lake Memorial Hospital? *

    If yes, what department and what is the person’s relationship to you?

    Have you ever been employed by Bear Lake Memorial Hospital?*

    If yes, when?

    What was your position?

    Why did you leave?

    Are you eligible to work in the United States? *

    Are you under 16 years of age?*

    If yes, please state the date of your birth:

    Check each of the following with which you have experience, and indicate your skill level:

    PC : 12345

    Windows : 12345

    Internet : 12345

    Email : 12345

    Word : 12345

    Excel : 12345

    Access : 12345

    PowerPoint : 12345

    QuickBooks : 12345

    Other :

    List other specific software programs you have used

    List relevant equipment / machinery you have operated:

    Typing Speed (WPM)

    10 Key (SPM)


    Have you graduated from High School or completed the GED equivalent?*

    List your highest degree first:



    Years Completed

    Type of Degree/Diploma/Certificate

    Are you currently enrolled? YesNo


    List all professional licenses, registrations, and certifications:


    License Number


    Expiration Dater

    Do you have any pending restrictions and/or suspensions on your current professional license/registration?*YesNo

    Have you ever been refused professional licensure, or had a license / registration suspended or revoked?*YesNo

    If yes, please explain:

    Please mark all current certifications:


    List any trade or professional organization of which you are a member. Include offices held:

    List any additional special skills:


    Starting with your most recent employment, give a complete record of all employment, including any breaks in employment. Use additional sheets if necessary. A resume will not be accepted as a substitute for this section.




    If your employment records exist under another name, please specify

    May we contact your previous employers?*YesNo If no, please explain:

    Have you ever been discharged from a job or asked to resign?*YesNo If yes, please explain:

    Please describe any lapses in employment during the previous seven years, stating dates and reasons

    How many years of employment do you have directly related to the position for which you are applying?*

    Upload Resume*


    Please list three professional references*




    Telephone Number

    Years Known

    CERTIFICATION AND AGREEMENT (Please read the following before signing)

    I certify that the information I provided in this application is complete and accurate to the best of my knowledge. I understand that any misrepresentation or omission of facts in this application disqualifies me from further consideration, or, if I am employed, is sufficient cause for dismissal regardless of when the misrepresentation or omission of fact is discovered

    I authorize investigation of all statements contained in this application and understand that I may be required to provide verification (diploma, license, transcripts, type tests, etc.) of information contained in this application. I authorize any and all persons, companies, or agencies to release to Bear Lake Memorial Hospital any and all information they may have, which is relevant to the application process. I also release all such parties from any liability that may result from furnishing information to Bear Lake Memorial Hospital. I understand that to be considered as a formal applicant, the position for which I am applying must be specifically identified as open, and recruitment for the position ongoing at the time this application is received by the Human Resources Department.

    I understand that if I am employed with Bear Lake Memorial Hospital, my employment will be at-will. As such it can be terminated by me or by Bear Lake Memorial Hospital with or without advance notice, at any time, and for any reason not prohibited by law.

    I agree that if I am employed by Bear Lake Memorial Hospital, I will review the information contained in the Employee Handbook and follow the policies described therein.

    I understand that any employment offer is contingent upon the following: (1) producing documents establishing my eligibility to work in the United States; (2) satisfactorily passing the pre-employment drug screen, employee health evaluation (if required), establishing that I am able to perform the essential functions of the position; the completion of a criminal background and reference checks; and (3) complying with Bear Lake Memorial’s pre-employment application procedures.

    I have not been excluded, suspended or debarred from participating or providing services in any Medicare/Medicaid program or any other federally funded health care program, nor am I being investigated in any matter that could lead to my exclusion from a Medicare/Medicaid program or any other federally funded health care program.

    I acknowledge that I have read the certification and agreement, and agree to abide by its terms.

    Applicant Signature