Careers at Waverly Health Center: Online Application
Position Applied For:
General Application
Please check the specific categories that best match your skillset. This way we will be able to direct your general application to the best hiring managers.
Clerical/Administrative Support
Management
Nursing
Other Direct Patient Care (non-nursing)
Physician/Provider
Support (Nutrition/Environmental/Plant Services)
SECTION ONE: PERSONAL INFORMATION
First Name
Middle Initial
Last Name
Address
City
State
Zip Code
Home Phone Number
Cell Phone Number
E-mail Address
SECTION TWO: JOB OPPORTUNITY
1.
How did you learn about this position? (Be specific with names)
2.
What type of position are you seeking:
Full-time
Part-time
PRN
Temporary
2a.
If part-time is selected, how many hours per week are you willing to work?
3.
Shift Preference:
1st
2nd
3rd
Weekends
4.
Have you ever been previously employed by Waverly Health Center?
Yes
No
4a.
If yes, please identify dates and position.
5.
List names and relationships of any relatives who are currently employed by us.
SECTION THREE: EMPLOYMENT AUTHORIZATION
1.
Are you at least 18 years of age?
Yes
No
2.
Are you authorized to work in the US?
Yes
No
SECTION FOUR: CRIMINAL HISTORY
1.
Have you ever been convicted of a felony? If yes, please explain.
Yes
No
2.
Do you have any record of Dependent Adult or Child Abuse? If yes, please explain.
Yes
No
3.
Has the Office of Inspector General ever sanctioned you for Medicare Fraud and Abuse? If yes, please explain.
Yes
No
4.
Has the General Services Administration ever excluded you from participation in any Federal or State health care program or debarred you from participation in any Federal procurement program? If yes, please explain?
Yes
No
SECTION FIVE: DRIVER'S LICENSE AND MOTOR VEHICLE RECORD
1.
If the position you are applying for requires you to drive, please answer these three questions:
a.
Do you have a current and valid Iowa driver's license?
Yes
No
b.
Have you ever been denied a driver’s license, or convicted of a moving traffic offense, including, but not limited to driving while intoxicated or reckless driving?
Yes
No
c.
Do you have proof of automobile insurance?
Yes
No
SECTION SIX: EDUCATION AND SKILLS
High School/College
Nursing School etc.
City/State
Degree, Major
or Program
Number of Years
Completed
Did You
Graduate?
1.
Yes
No
2.
Yes
No
3.
Yes
No
4.
Yes
No
Please list any relevant computer software experience or knowledge:
Please rate your computer skills:
Beginner
Some Knowledge
Average
Very Comfortable
Expert
SECTION SEVEN: PROFESSIONAL PRACTICE REQUIREMENTS
Type
License or Cert Number
State Issued
Expiration Date
1.
2.
3.
SECTION EIGHT: ADDITIONAL INFORMATION
Please include any additional information that you think would be applicable (for example: internships, membership in professional organizations). EXCLUDE any information which would denote race, color, religion, gender, sexual orientation, national origin, age, disability or marital status.
SECTION NINE: EMPLOYMENT HISTORY
Please give a complete record of all employment, starting with present or most recent employer.
All applicants must complete this section, even if you will attach a resume.
1.
Company Name
Telephone
Address
City, State
Employed From
mm/yyyy
Employed To
mm/yyyy
Manager's Name
Hourly Wage
Hours Worked Per Week
May we contact this employer?
Yes
No
Job Titles/Duties
(1000 Character Max - please be specific)
Reason for Leaving
2.
Company Name
Telephone
Address
City, State
Employed From
Employed To
Manager's Name
Hourly Wage
Hours Worked Per Week
May we contact this employer?
Yes
No
Job Titles/Duties
(1000 Character Max - please be specific)
Reason for Leaving
3.
Company Name
Telephone
Address
City, State
Employed From
Employed To
Manager's Name
Hourly Wage
Hours Worked Per Week
May we contact this employer?
Yes
No
Job Titles/Duties
(1000 Character Max - please be specific)
Reason for Leaving
4.
Company Name
Telephone
Address
City, State
Employed From
mm/yyyy
Employed To
mm/yyyy
Manager's Name
Hourly Wage
Hours Worked Per Week
May we contact this employer?
Yes
No
Job Titles/Duties
(1000 Character Max - please be specific)
Reason for Leaving
SIGNATURE & CONFIRMATION
Mission, Vision and Values
Yes, I have read Waverly Health Center’s mission, vision, and values and I accept and understand that all employees of Waverly Health Center are expected to commit to all three.
Click here to review Waverly Health Center's Mission, Vision and Values.
Pre-employment Requirements
Yes, I agree to Waverly Health Center’s pre-employment requirements.
Click here to review the pre-employment requirements.
Terms and Conditions
Yes, I agree to Waverly Health Center’s terms and conditions of employment.
Click here to review the terms and conditions.
Please list your maiden name or any former names associated with your social security number:
Digital Signature
Please type your name as you would sign it, verifying that all information provided in this application is accurate to the best of your knowledge.
It is the policy of Waverly Health Center, an Equal Opportunity and Affirmative Action Employer, that all persons employed will be treated equally without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, or marital status, except where these categories are a bonafide occupational qualification.
Waverly Health Center complies with the Iowa Smokefree Air Act, which prohibits smoking in almost all public places and enclosed areas within places of employment. Please visit
http://www.iowasmokefreeair.gov/
for more information.
Waverly Health Center participates in E-Verify to validate employment eligibility and authorization for all new employees. Please visit
http://www.uscis.gov/e-verify
for more information.
All Rights Reserved © 2007 Waverly Health Center
Waverly Health Center - 312 9th Street SW - Waverly, IA 50677 - (319) 352-4120
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