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WYOMING VALLEY HEALTH CARE SYSTEM, INC.

HUMAN RESOURCE DEPARTMENT

575 NORTH RIVER STREET

WILKES-BARRE, PA 18764

(570) 552-8800

EMPLOYMENT APPLICATION


DATE
POSITION DESIRED

LAST NAME
FIRST NAME	M.I.

EMAIL ADDRESS

ADDRESS	APT.#

CITY	STATE
ZIP

PHONE	SOC. SEC. #

WERE YOU PREVIOUSLY EMPLOYED BY WVHCS? Yes No

IF YES: DEPARTMENT	POSITION

DATE TERMINATED

LAST NAME	(if different)
REASON FOR LEAVING


If you are under 18 years of age can you provide proof of your eligibility to work?	Yes No

Are you either a U.S. citizen or alien who has the legal right to remain and work in the U.S.A?	Yes No

(You will be required to furnish documents proving identity and eligibility to work in the U.S.A. if you are extended a job offer.)

REQUESTED STATUS (check all that interest you)

Full Time (80 hours bi-weekly)	Part Time Benefit (40 hours or more bi-weekly)	Part Time No Benefit (39 hours or less bi-weekly)	Temporary	Per Diem
Days	Evenings	Nights	Weekends	Holidays
Overtime	Rotation shift

How were you referred to WVHCS?

Have you ever been convicted of a crime, excluding those convictions which have been annulled, expunged or sealed by the Court?

Yes No (conviction will not necessarily disqualify an applicant from employment)

If yes, please explain in detail

EDUCATION

SCHOOL	Name/Address of School	Course of Study	From to (years)	Last year completed	Did You Graduate	Diploma/Degree

Elementary/High					Yes No

Business, Trade or Technical					Yes No

College/University					Yes No

Graduate					Yes No

MILITARY SERVICE

BRANCH OF MILITARY SERVICE

Date entered Date discharged

Do you have military service-related skills and experience applicable to civilian employment ? Yes No

If yes, please describe:

WORK HISTORY: (Begin with most recent jobs)
Employer: Address:
Phone number: Start date: Termination date:
Job title: Supervisor name:
Reason for leaving: Ending rate of pay:
Work performed:

WORK HISTORY:
Employer: Address:
Phone number: Start date: Termination date:
Job title: Supervisor name:
Reason for leaving: Ending rate of pay:
Work performed:

WORK HISTORY:
Employer: Address:
Phone number: Start date: Termination date:
Job title: Supervisor name:
Reason for leaving: Ending rate of pay:
Work performed:

SKILLS:
	Typing/Word Processing	Shorthand	Transcription
	Microsoft Office	Spreadsheets	Graphs
	Medical Terminology	Unity 22
List all other special skills you possess:

LICENSURE/REGISTRATION/CERTIFICATION (Professional Applicants):
Current Licensure/Registration/Certification
License/Reg./Cert. No.
State (s)
Expires

List individuals familiar with your professional skills who are not relatives or employers.
Name:

Title:

Street:

City:

State:	Zip code:

Telephone number:

May we contact?	Yes No

Name:

Title:

Street:

City:

State:	Zip code:
Telephone number:
May we contact?	Yes No

The facts set forth in my application for employment are true and complete

I hereby authorize investigation of all statements contained in this application for employment and/or any other document completed by me in connection with my employment; I permit a detailed employment check including but not limited to a check with previous employers; I hereby give Wyoming Valley Health Care System, Inc. and the criminal background check service designated by the System permission to use this information to perform a criminal background investigation, Criminal History Record Check, Child Protective Agencies Check, etc. and/or Division of Motor Vehicles Record Check and I release the System from any and all liability from such investigation. I understand that any false statement, misrepresentation or omission of facts from this application may be cause for immediate dismissal. I further agree to undergo a pre-employment physical examination and any additional physical examinations that may be required in connection with my continued employment. Also, I hereby give my consent to such physicians to report their findings to the employer.

I hereby attest that I am not currently nor do I anticipate designation as an Excluded Individual as determined by the HHS/OIG and/or GSA. Additionally, I will disclose such designation immediately to WVHCS should I have or attain status as an Excluded Individual as determined by the HHS/OIG and/or GSA.


Signature of Applicant	Date

AN EQUAL OPPORTUNITY EMPLOYER

The Wyoming Valley Health Care System, Inc. is an equal opportunity employer. No person shall be unlawfully excluded from consideration for employment because of race, color, religious creed, national origin, ancestry, sex, age, non-job related medical condition or handicap, marital or veteran status or any other legally protected status. This application will be kept on file for a period of one year.

OUR CORE VALUES

Integrity, Accountability, Teamwork, Compassion and Courtesy - are the foundation upon which all of our interactions take place. These core values provide Wyoming Valley Health Care System with a sound basis as we strive to ensure an ethical and compassionate approach to health care delivery and management. They define our entire System and all that we work to achieve. All employees are expected to be in compliance with our Core Values.