Nurse-staff

Employment Application

Please completely fill out the following application. Incomplete applications will not be accepted. If your application meets our hiring criteria, you will be contacted. 


 

Questions with an asterisk (*) are required.
About You
* First Name:
* Last Name:
* Email Address:
* Phone Number:
* Address:
* City:
* State:
* Zip:
* Position Desired:
* Are you a U.S. citizen or an alien legally authorized to work in the United States?
* Are you under 18 years of age?
Association with MMC
* Do any of your relatives work for Modoc Medical Center?
If so, please provide their full name and your relationship:
* Have you ever been employed with us before?
If so, give dates and full name used:
Work Needs/Preferences
* Do you need any accommodations to physically perform the duties of the job for which you are applying?
Are you available to work:
Education, Skills
* Please enter the name and address of the high school you attended, and if a diploma was received:
* Please enter the name and address of all colleges attended, course of study and any degrees received (if you have not attended any higher education courses please type None):
* Have you had any job-related training in the United States military?
* List any licenses and/or certifications that you have obtained, the state issued in, date of issuance, and number:
Current/Most Recent Employer
* Employer’s Name:
* Employer’s Phone Number:
* Employer’s Address:
* Your Title:
* Dates of employment:
* May we contact your current employer?
Previous Employer
*List your previous employer, their phone number and address, title, dates of employment, and reason for leaving:
Previous Employer
*List your previous employer, their phone number and address, title, dates of employment, and reason for leaving:
Additional Information
*Please list three professional references and their contact information: (Do not list relatives)
Please share any other additional relevant information below:
* How did you learn about us?
Terms & Conditions

In consideration of my employment, I agree to conform to the rules and regulations of this facility. I understand that my employment can be terminated at any time and for any reason at the option of either the facility or myself. I understand that no one 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, except for in a written employment agreement signed by an administrative representative of the facility. I hereby affirm that the information provided on this application is true and that falsifying this document may disqualify me from further consideration for employment and may result in discharge, even if discovered at a later date. In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, disability or any other legally protected group status. Modoc Medical Center is an equal opportunity employer.

* I agree
*