Harney District Hospital
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Obstetric Nurse

Sure, Harney District Hospital is a great place to work. Even more important, Harney County is a great place to live!

To find out more about us and the job opportunities available, please complete the following application, or simply e-mail your resume to Denise Rose, Hospital Development and Recruiting along with a note regarding the type of job you're interested in. We want to hear from you!

 

**Indicates a required field.

PERSONAL INFORMATION                          

First Name   

**

  

Last Name   

**  

Address   

City   

       

State   

Zip   

   

Phone   

**

Fax   

   

Date Available   

                 
Position Applied For
                 
If under 18 years of age, can you provide required proof of your eligibility to work? Yes   No    
If you are employed, can you provide proof of identy and authorization to work in the United States? Yes   No    
Are you able to perform the primary duties of the position for which you are applying as described in the advertisement, announcement, posting or job description with reasonable accommodation? Yes   No    
If no, please explain.
    
Have you ever been employed with us before? Yes   No    
If yes, please give dates employed and position title.    
May we contact your present employer?   Yes   No    
Have you ever been CONVICTED, pled GUILTY or NO CONTEST, or FORFEITED BOND or BAIL for any crime other than traffic violations? (Conviction of a crime is not an automatic bar to employment. Factors such as the nature and gravity of the crime, the length of time that has passed since the conviction and/or completion of any sentence, and the nature of the job for which you have applied will be considered). Yes   No    
If yes, please explain.
    
               
EDUCATION INFORMATION                        
High School
City/State    
Years Completed
Diploma/Degree    
Undergraduate College
City/State    
Years Completed
 Diploma/Degree    
Graduate/Professional
 City/State    
Years Completed
Diploma/Degree    
Other (Specify)
City/State    
Years Completed
Diploma/Degree    
Please indicate any foreign languages you can speak, read and/or write.
Please describe any specialized training, apprenticeships, skills and extra-curricular activities.
YOUR REFERENCES  
1. Reference Name
Reference Phone      
Address
    
2. Reference Name
Reference Phone      
Address
    
3. Reference Name
Reference Phone      
Address
    
EMPLOYMENT EXPERIENCE Begin with your present or last job. Please include any job-related military experience or volunteer activities.    
1. Employer Name
Employer Phone      
Address
    
Job Title
Supervisor Name      
Dates Employed
Rate/Salary      
Work Performed
   
2. Employer Name
Employer Phone      
Address
    
Job Title
Supervisor Name      
Dates Employed
Rate/Salary      
Work Performed
   
3. Employer Name
Employer Phone      
Address
    
Job Title
Supervisor Name      
Dates Employed
Rate/Salary      
Work Performed
   
4. Employer Name
Employer Phone      
Address
    
Job Title
Supervisor Name      
Dates Employed
Rate/Salary      
Work Performed
   
 
As an Equal Opportunity Employer, we consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status. No application will be rejected as a result of a disability that, with reasonable accommodation, does not prevent performance of the essential job duties.
You must submit a separate Application for Employment for each positon to which you are applying. Your Application for Employment will be valid for a 60-day period. Thank you for considering Harney District Hospital as your employer of choice.

 
    

 

  
     
             
         
VOLUNTARY AFFIRMATIVE ACTION DATA SHEET Please Note: Completion Of This Form Is Voluntary
Harney District Hospital considers all applicants for positions without regard to race, color, religion, gender, national origin, citizenship, sexual orientation, age, mental or physical disabilities, veteran or marital status or any other similarly protected status.
In an effort to comply with requirements regarding government recordkeeping, reporting and other legal obligations which may apply, we request you complete this applicant data survey. Providing this information is strictly voluntary. Failure to provide it will not subject you to any adverse personnel decision or action. Please be advised this survey is not part of your official application for employment and is not used in any employment decision. This form is sent to a separate e-mail ans is kept separated from your application. It will be kept confidential in accordance with applicable laws and regulations.

First Name   

**

  

Last Name   

**  

Address   

City   

       

State   

Zip   

   

Phone   

**

   

     
Position Applied For
                                   
Please indicate your gender Female   Male
Your Social Security number              
Your Referral Source State
Employment Office 		  Employment Agency          
  Current Employee   Walk-In          
  School   Relative          
  Other          
  Advertisement In          
Please check one of the following Identification Groups
         
Hispanic
White (not of Hispanic Origin)
Black
Asian/Pacific Islander
American Indian/Alaskan Native 		                                   
                                                 
Please indicate if any of the following apply to you                            
Disabled Veteran   Veteran of Vietnam Era   Veteran       Handicapped      
                                                 

 
    

 
       
 
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Harney District Hospital, 557 W Washington, Burns OR 97720
(541) 573-7281
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