Vista Healthcare-Long Term Acute Care Hospital-LTACH- servicing medically complex, critically ill patients suffering from chronic illnesses

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Online Application

PERSONAL

Last Name

First Name

Middle Name

Social Security Number

Home Address
Street	Apartment	City	State	Zip Code

Home Phone

Cell Phone

Email Address

Are you 18 years or over? Yes No
If hired, you will be requested to submit proof of age.

Name of person through whom you may be contacted for message purposes

Address

Phone

If hired, can you furnish proof that you are legally permitted to work in the United States? Yes No

What other name have you been employed under if different from present name?

Have you ever been convicted of a felony, miseameanor or infraction? Yes No
(Failure to provide the information will disqualify you from further employment)

If yes, please explain (NA if No) :

Indicate date, place and nature of each such conviction, pending charge or pending trial. The existence of a conviction or pending charge will not necessarily preclude you from employment. The nature of the crime and its relationship to the position applied for, the degree of rehabilitation of the applicant and the time elapsed since the crime or release from confinement will all be considered.

Names of relatives employed by this or another VISTA facility:
Name	Department
Name	Department
Name	Department

Have you been previously employed by Vista Hospital of South Bay or Community Hospital of Gardena? Yes No
If YES, where? (NA if No)	When? (NA if No)

Were you referred by an employee? Yes No

If YES, state name

EDUCATIONAL BACKGROUND

High School

Location

Last Grade Completed

Did you graduate?
Yes No

College

Location

Last Grade Completed

Degree or Major

Other education, special courses or academic honors

Colleges in which you are currently enrolled:

PROFESSIONAL LICENSES/CERTIFICATION

1	Type	Number	State Issued	Date Issued	Expires on	Confirmed
2	Type	Number	State Issued	Date Issued	Expires on	Confirmed
3	Type	Number	State Issued	Date Issued	Expires on	Confirmed

LIST ANY PROFESSIONAL ORGANIZATIONS OF WHICH YOU ARE A MEMBER (You may omit any which indicates sex, religion, national origin, ancestry, handicap or disability, race, age, sexual orientation, marital status, or Veterans status):

SKILLS

Typing Speed
( Last Date Tested)

Shorthand Speed
(Last DateTested)

10 Key Add. Mach. by touch
Yes No

PBX (Type Board)
Yes No

Medical Terminology
Yes No

List other knowledge or skills you possess or equipment you can operate:

TYPE OF EMPLOYMENT DESIRED

First Choice

Second Choice

Date Available

Salary Desired

Hours & Shift Available
Full Time Yes No	Part Time Yes No	Per Diem Yes No	Days Yes No	Evenings Yes No	Nights Yes No	Weekends Yes No

EMPLOYMENT HISTORYMOST RECENT EMPLOYER FIRST - Explain any lapses in employment between jobs

EMPLOYER #1

Present or previous company

May we contact? Yes No

Phone number

Address

Full Time Part Time Per Diem

Average hours weekly

Job Title

Immediate Supervisor

Nature of duties

Employed from (mm/yyyy)

Employed to (mm/yyyy)

Hour Salary:

Start

End

Reason for leaving (also indicate resigned, discharged, etc.)

Explain time lapse:

EMPLOYER #2

Present or previous company

May we contact? Yes No

Phone number

Address

Full Time Part Time Per Diem

Average hours weekly

Job Title

Immediate Supervisor

Nature of duties

Employed from (mm/yyyy)

Employed to (mm/yyyy)

Hour Salary:

Start

End

Reason for leaving (also indicate resigned, discharged, etc.)

Explain time lapse:

EMPLOYER #3

Present or previous company

May we contact? Yes No

Phone number

Address

Full Time Part Time Per Diem

Average hours weekly

Job Title

Immediate Supervisor

Nature of duties

Employed from (mm/yyyy)

Employed to (mm/yyyy)

Hour Salary:

Start

End

Reason for leaving (also indicate resigned, discharged, etc.)

Explain time lapse:

PROFESSIONAL REFERENCES Please list three persons not related to you who have knowledge of your work performance within the last ten (10) years. All references will be contacted.

1	Name	Telephone No.	Occupation
	Address		Years Acquainted

2	Name	Telephone No.	Occupation
	Address		Years Acquainted

3	Name	Telephone No.	Occupation
	Address		Years Acquainted

I hereby certify that the information contained in this application form is true and correct to the best of my knowledge and I authorize an investigation of any of the facts set forth in this application. I give permission to check my educational background, employment, references, professional license, criminal record (both federal and state), and driving record . I authorize the references listed above to provide the Hospital any and all information concerning my previous employment and any pertinent information that they may have. Further, I release all parties and persons from any and all liability for any damages that may result from furnishing such information to the Hospital as well as from the use or disclosure of such information by the Hospital or any of its agents, employees, or representatives. I understand that any misrepresentation, falsification, or material omission of information on this application may result in my failure to receive an offer or, if I am hired, in my dismissal from employment.

In consideration of my employment, I agree to conform to the rules and standards of the Hospital and agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, either at my option or at the option of the Hospital. I understand and agree that my employment with the Hospital is entered voluntarily. I understand that no employee or representative of the Hospital other than the Chief Executive Officer has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing. Further, the Chief Executive Officer may not alter the at-will nature of the employment relationship unless he does so specifically and in writing. I also understand that all offers of employment are conditioned on the provision of satisfactory proof of an applicant's identity and legal right to work in the U.S.

I understand that any offer of employment with the Hospital will be conditioned on completing a satisfactory background check, pre-employment medical examination and a pre-employment drug and alcohol test. The purpose of the medical examination is to determine whether I am able to perform the essential functions of the job I am offered with or without reasonable accommodation, to identify any reasonable accommodation if such is warranted, and to ensure that my performance of the essential functions does not present a direct threat to my health and safety or the health and safety of others. I agree to undergo such a pre-employment medical examination and drug and alcohol test. If hired by the Hospital, I further agree to undergo any periodic medical examinations, which are permitted or required by law.