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Press
Leadership
Rural Community Health
Services
Back and Spine
Elbow
Emergency Care
Foot & Ankle
Hand & Wrist
Hip
Joint Replacement
Knee
Neck Pain
MAKOplasty® Hip Replacement
MAKOplasty® Partial Knee Replacement
Pain Management
Physical Therapy
Shoulder
Sports Medicine
Trauma, Fractures and Tendon Repair
Our Physicians
Jean J. Bernard, M.D.
Darnell Blackmon, M.D.
Brian Chalkin, M.D.
Gregory Holt, M.D.
Yogesh Mittal, M.D.
Victor Palomino, D.O.
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Employment Application
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Employment Application
About You
First Name
Last Name
E-mail:
Date:
Address
*
Street Address
Address Line 2
City
State
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Alaska
Arizona
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Armed Forces
Zip Code
Social Security Number*
Home Phone
Work Phone
Emergency Phone
Are you over the age of 18?
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No
Able to perform job duties?
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No
Authorized to work in U.S.?
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No
Are you a convicted felon?
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No
How did you hear about this position?
Have you ever employed with us before?
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No
List any relatives currently employed with us
Employment Desired:
FT
PT
PRN
Numbers of hours per week
Available Start Date
Location &/or Position applied for
Current Salary
Requested Salary
Days of the week willing to work
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Education
High School
High School Name and Location
High School Major
High School Degree
College
College Name and Location
College Major
College Degree
Technical School
Technical School Name and Location
Technical School Major
Technical School Degree
Secondary School
Secondary School Name and Location
Secondary School Major
Secondary School Degree
Other Training or GED
Other Training or GED Name and Location
Other Training or GED Major
Other Training or GED Degree
Licensures Held
Please enter licenses held in this box along with Licensure Name, Licensure number, Licensure Exp Date, Original State and restrictions, if any
Current Employer
Latest Employer Start Date:
Latest Employer End Date:
Latest Employer Name
Latest Employer Telephone
Latest Employer Street Address
Latest Employer Address Line 2
Latest Employer City
Latest Employer State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
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Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
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Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces
Latest Employer Zip
Latest Employer Job Title
Latest Employer Immediate Supervisor
Latest Employer Hourly Rate/Salary
Latest Employer Job Duties
Latest Employer Reason for Leaving
Previous Employer
Previous Employer Start Date:
Previous Employer End Date:
Previous Employer Name:
Previous Employer Street Address
Previous Employer Address Line 2
Previous Employer City
Previous Employer State
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Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces
Previous Employer Zip
Previous Employer Job Title
Previous Employer Immediate Supervisor
Previous Employer Hourly Rate/Salary
Previous Employer Job Duties
Previous Employer Reason for Leaving
Terms and Conditions
Terms And Conditions
I hereby authorize Bristow Medical Center, including any of its affiliates, to obtain from my former employers all data and records, including the same from a consumer-reporting agency needed to support this application. I hereby release my former employers and individuals connected therewith, and further release Bristow Medical Center from all liability for any damage whatsoever incurred in furnishing such information. I hereby certify that the foregoing statements are to the best of my knowledge true and correct, and I agree that any misstatements or omissions of material facts will constitute grounds for denial of or dismissal from employment. I hereby acknowledge that I am willing to work the scheduled shifts pursuant to the employee handbook. I am aware my employment may be conditioned upon the successful completion of a post-offer physical examination which will include a test for substance abuse, and receipt of valid documentation verifying my eligibility for employment. In consideration of my employment, I agree to conform to all local state and federal laws and to the rules regulations policies and procedures of Bristow Medical Center. In addition, I understand and agree that any employee handbook, which I may receive, will not constitute an employment contract, but will be a general statement of Bristow Medical Center’s policies. I further understand that employment is at will.
Agree to Terms
I agree to the authorization terms as listed above
In addition to work history, are there other skills, qualifications, or experience that we should consider?
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References
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Reference 1 Address
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Reference 1 Years Known
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