Application For Employment

Apply on online using the electronic form below or download and print the pdf form to apply for current positions, or positions that may become available in the near future. Please return/mail/fax the application form to the HR Department at:

Central Valley Medical Center
48 W 1500 N, Nephi, UT 84648
FAX: 435-623-3290.

DOWNLOAD APPLICATION FORM HERE >>  Application Form - PDF ( 90KB )

Position applied for:*     
Date of application:        (mm/dd/yy)

First Name:*      
Middle Name:   
Last Name:*      


Street Address:*   
City:*                    
State:*                  
Zip Code:*            


Telephone #:*                         (nnn)-nnn-nnnn

Cell/Beeper/Other Phone #:     (nnn)-nnn-nnnn
Email Address:*      

May we contact you at work?* Yes No
If yes, work number and best time to call:     (nnn)-nnn-nnnn: explanation

If you are under 18 and it is required, can you furnish a work permit?* Yes No

Have you ever been employed here before?*       Yes No
If yes, please give dates -   From:   To:   (mm/dd/yy)

Date available for work:*   (mm/dd/yy)

Type of work desired:*     Full-Time Part-Time Temporary

Will you relocate if job requires it?* Yes No

Will you travel if job requires it?* Yes No

Are you able to meet the attendance requirements of the position?* Yes No
If no, please explain:   

Have you ever been convicted of a felony?* Yes No
If yes, please explain:   

Answering "yes" to this question does not constitute and automatic bar to employment.
Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.


Employment History:

Provide the following information of your past and current employers, assignments,
or volunteer activities, starting with the most recent.

CURRENT EMPLOYER:

1. NAME OF EMPLOYER:*        
2. EMPLOYER TELEPHONE:*          (nnn)-nnn-nnnn
3. DATES EMPLOYED:*   FROM:    TO:    (mm/dd/yy)
4. SUMMARIZE JOB FUNCTIONS AND RESPONSIBIITIES:*
    
5. EMPLOYER ADDRESS:*           
6. STARTING JOB TITLE:*              
7. FINAL JOB TITLE:*                     
8. STARTING HOURLY RATE/SALARY:*               
9. IMMEDIATE SUPERVISOR AND TITLE:*            
10. REASON FOR LEAVING:*                        
11. FINAL HOURLY RATE/SALARY:*            
12. CONTACT NAME FOR REFERRANCE:*   
    Yes No Later

PREVIOUS EMPLOYER (#1):

1. NAME OF EMPLOYER:        
2. EMPLOYER TELEPHONE:          (nnn)-nnn-nnnn
3. DATES EMPLOYED:   FROM:    TO:    (mm/dd/yy)
4. SUMMARIZE JOB FUNCTIONS AND RESPONSIBIITIES:
    
5. EMPLOYER ADDRESS:           
6. STARTING JOB TITLE:              
7. FINAL JOB TITLE:                     
8. STARTING HOURLY RATE/SALARY:               
9. IMMEDIATE SUPERVISOR AND TITLE:            
10. REASON FOR LEAVING:                        
11. FINAL HOURLY RATE/SALARY:            
12. CONTACT NAME FOR REFERRANCE:   
    Yes No Later

PREVIOUS EMPLOYER (#2):

1. NAME OF EMPLOYER:        
2. EMPLOYER TELEPHONE:          (nnn)-nnn-nnnn
3. DATES EMPLOYED:   FROM:    TO:    (mm/dd/yy)
4. SUMMARIZE JOB FUNCTIONS AND RESPONSIBIITIES:
    
5. EMPLOYER ADDRESS:           
6. STARTING JOB TITLE:              
7. FINAL JOB TITLE:                     
8. STARTING HOURLY RATE/SALARY:               
9. IMMEDIATE SUPERVISOR AND TITLE:            
10. REASON FOR LEAVING:                        
11. FINAL HOURLY RATE/SALARY:            
12. CONTACT NAME FOR REFERRANCE:   
    Yes No Later

Comments (Including explanation of any gaps in employment):     

Skills and Qualifications:     

Summarize any special training, skills, licenses and/or certificates to describe your qualifications.


Educational Background (if job related):     

Are you a high school graduate?*   Yes No
Name of High School/City/State:   



Higher Education:

A. List last three (3) schools attended, starting with the most recent: 
1.   2.   3.  

B. List number of years completed:     
C. Indicate degree earned, if any:        
D. Major field of study:                       



References:

List name and telephone number of three business/work references that are NOT related to you and are NOT previous supervisors. If not applicable, list three school or personal references that are not related to you:


NAME:   TELEPHONE:   YEARS KNOWN: 

NAME:   TELEPHONE:   YEARS KNOWN: 

NAME:   TELEPHONE:   YEARS KNOWN: 



Additional Information:

1. List professional, trade, business or civic associations and any offices held:
(exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve national guard or any similarly protected status):

ORGANIZATION:    OFFICES HELD:  

2. List any additional information you would like us to consider:




Professional Resume:

Paste Resume Here:



Accuracy Check of Applicant:

I authorize the companies, schools or my current employer, if applicable, and previous employers and organizations named in this application (and accompanying resume, if any), to provide Central Valley Medical Center with any relevant information regarding an employment decision.

I give authorization

 
I agree that all questions asked and information released in good faith shall be privileged, and I expressly release Central Valley Medical Center, such employers, such other persons and any of their authorized representatives, from any and all liability arising from questions asked, information released or statements made.

I agree

 
I understand that my employment with Central Valley Medical Center, Nephi Medical Center, Central Valley Home Health, Central Valley Hospice, Central Valley Community Pharmacy and/or Fountain Green Medical Clinic is contingent upon the following:
1. The results of a drug/alcohol screening, analysis for substance abuse, the positive results of which will be grounds for disqualifying me for employment.
2. My ability to provide verification of a U.S. Citizenship, lawful permanent residency, or other proof of a work authorization document, or a combination of documents as specified in Section 2 of the Employment Eligibility Verification (Form 1-9).
3. Ability to verify education and licensure if applicable.

I understand

 
Central Valley Medical Center is an equal opportunity employer and no question on this form is asked for the purpose of limiting or excluding any applicant's consideration because of race, color, sex, national origin, age, marital status, or disability. Central Valley Medical Center follows the rules and regulations governing fair employment practices and respects the applicant's right to privacy and that all inquiries will be treated in confidence.

I understand

 
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 of contract for employment for any specified periods or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president.

I understand

 
I understand that Central Valley Medical Center maintains a smoke-free environment.

I understand

 
By submitting this application electronically, I attest that information stated in my application for employment is true and correct. I hereby understand that if I am employed, false statements on this application shall be considered sufficient cause for dismissal.

I understand

Date:    




* Denotes required fields. Please, only submit form once.