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Castle Rock Medical Center
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Job Application Ambulance Biller/Coder
Job Application - Part-time Medical Lab Tech
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Secure Application for Employment
It is the policy of this facility to provide equal opportunity to persons regardless of race, religion age, gender, disability or any other classification in accordance with federal, state and local statutes, regulations and ordinances.
This Application can be active as long as legally required.
Date
MM slash DD slash YYYY
Name
First
Middle
Last
Are you at least 18 years old?
Yes
No
Primary Phone
Secondary Phone
Present Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Email
Current Open Position for Which You Are Applying for: Medical Laboratory Tech
Are you currently credentialed for the position for which you are applying?
Select One
Yes
No
Type of Position
Select One
Full Time
Part Time
PRN
Temporary
Shift
Select One
Weekend
Day
Night
Evening
Rotation
Salary Requirement ($)
If overtime work is required periodically, does this pose a problem for you?
Select One
Yes
No
Date Available For Work
MM slash DD slash YYYY
Are You Legally Authorized to Work in the U.S.?
Select One
Yes
No
Have you ever worked for Castle Rock Hospital District?
Select One
Yes
No
Are you related to another facility employee?
Select One
Yes
No
How did you learn about this position?
College Placement Office
Employee Referral
Employment Advertisement
Social Media
Our Website
Other
Which employee referred you?
Which advertisment?
Please tell us more.
Are you able to perform the essential, job related functions of the position for which you are applying with or without reasonable accommodations?
Select One
Yes
No
Have you been convicted of a crime and/or released from confinement following a conviction for any criminal offense?
Arrests or charges that have been expunged need not be disclosed. Select One
Yes
No
If yes, Give date, place and nature of each such conviction.
Are you currently excluded from participation in any federally funded healthcare program - including Medicare and Medicaid - and are you aware of any potential exclusion from a federally funded health program?
Select One
Yes
No
Educational History
High School
School Name
City
State / Province / Region
Check last year attended
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10
11
12
Graduated / GED
Select One
Graduated
GED
College
School Name
City
State / Province / Region
Check last year attended
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2
3
4
Graduated from college #1?
Select One
Yes
No
Are you currently attending or enrolled in college?
Select One
Yes
No
College #1 Degree
College 2 (if applicable)
School Name
City
State / Province / Region
Check last year attended
1
2
3
4
Graduated from college #2?
Select One
Yes
No
College #2 Degree
Graduate School (if applicable)
School Name
City
State / Province / Region
Check last year attended
1
2
3
4
Graduated from graduate school?
Select One
Yes
No
Graduate Degree
Licensing and Certifications
List any professional licenses, registration or certification you possess (Include Driver's License, if applicable)
License/Registration/Certification
Number
State Issued
Expiration Date
License/Registration/Certification
Number
State Issued
Expiration Date
License/Registration/Certification
Number
State Issued
Expiration Date
License/Registration/Certification
Number
State Issued
Expiration Date
License/Registration/Certification
Number
State Issued
Expiration Date
Does the position you are applying for require you to drive?
Yes
No
Do you have a valid driver's license?
Yes
No
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
If yes, please provide details.
Do you have proof of automobile insurance?
Yes
No
Clerical or other skills applicable to the position for which you are applying
Email
Internet
Microsoft Excel, Word, and PowerPoint
Other
Other - Tell us more
Work History
Please list all work history from most recent to oldest.
Current or Most Recent
From Month
From Year
To Month
To Year
Company
Job Title
Salary ($)
Immediate Supervisor
Address
Street Address
Phone
May we contact them?
Select One
Yes
No
Name while employed
Nature of duties
Reason for leaving
# Hrs/Week
PRN
Full-Time
Part-Time
If part-time, how many hours per week?
Previous
From Month
From Year
To Month
To Year
Company
Job Title
Salary ($)
Immediate Supervisor
Address
Street Address
Phone
May we contact them?
Select One
Yes
No
Name while employed
Nature of duties
Reason for leaving
# Hrs/Week
PRN
Full-Time
Part-Time
If part-time, how many hours per week?
Previous
From Month
From Year
To Month
To Year
Company
Job Title
Salary ($)
Immediate Supervisor
Address
Street Address
Phone
May we contact them?
Select One
Yes
No
Name while employed
Nature of duties
Reason for leaving
# Hrs/Week
PRN
Full-Time
Part-Time
If part-time, how many hours per week?
Previous
From Month
From Year
To Month
To Year
Company
Job Title
Salary ($)
Immediate Supervisor
Address
Street Address
Phone
May we contact them?
Select One
Yes
No
Name while employed
Nature of duties
Reason for leaving
# Hrs/Week
PRN
Full-Time
Part-Time
If part-time, how many hours per week?
Professional References (other than relatives)
Give references who have good knowledge of your work.
Name
Position
Relationship
Phone
Email
Name
Position
Relationship
Phone
Email
Name
Position
Relationship
Phone
Email
Name
Position
Relationship
Phone
Email
Upload Resume
Drop files here or
Select files
Max. file size: 50 MB.
Review and Submission
Please review and acknowledge that you understand the following. In submitting this application for employment: * I certify that the information in this application is true and complete for all practical purposes. It may be verified by the facility. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the facility is relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse. I authorize Castle Rock Hospital District to thoroughly investigate my references, work record, education and other matters related to my suitability for employment, (e.g., motor vehicle operator records, criminal records, school records, licensure records, etc. ) and further authorize the references I have listed to disclose to the company and all letters, reports, and other information related to my work records, without giving me prior notice of such disclosure. In addition, I release Castle Rock Hospital District, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure. I UNDERSTAND AND AGREE THAT ANY POLICIES WHICH I MAY RECEIVE WILL NOT CONSTITUTE AN EMPLOYMENT CONTRACT. Compliance with this facility's Substance Abuse Policy is a condition of employment. This hospital requires that every newly hired employee be free of drug abuse. I understand and acknowledge that I may be required to submit to a physical examination, including drug testing. I hereby authorize the release of the results of such an examination to Castle Rock Hospital District for their use in evaluating my suitability for employment. Further, I release the examining facility and Castle Rock Hospital District from any and all liability, and from any damage that may result from the release of such information. Each offer of employment is contingent upon successfully completing a urinalysis test/screen for drugs in accordance with hospital policy. * I UNDERSTAND AND AGREE THAT IF I AM OFFERED EMPLOYMENT BY THE FACILITY, MY EMPLOYMENT WILL BE FOR NO DEFINITE TERM AND THAT EITHER I, OR THE FACILITY WILL HAVE THE RIGHT TO TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, I ALSO UNDERSTAND THAT THIS STATUS CAN ONLY BE ALTERED BY A WRITTEN CONTRACT OF EMPLOYMENT WHICH IS SPECIFIC AS TO ALL MATERIAL TERMS AND IS SIGNED BY ME AND THE ADMINISTRATOR OF THE FACILITY. Release: I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my license status and my license history.
Please review and acknowledge that you understand the following.
In submitting this application for employment: * I certify that the information in this application is true and complete for all practical purposes. It may be verified by the facility. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the facility is relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.
I authorize Castle Rock Hospital District to thoroughly investigate my references, work record, education and other matters related to my suitability for employment, (e.g., motor vehicle operator records, criminal records, school records, licensure records, etc. ) and further authorize the references I have listed to disclose to the company and all letters, reports, and other information related to my work records, without giving me prior notice of such disclosure. In addition, I release Castle Rock Hospital District, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
I UNDERSTAND AND AGREE THAT ANY POLICIES WHICH I MAY RECEIVE WILL NOT CONSTITUTE AN EMPLOYMENT CONTRACT.
Compliance with this facility's Substance Abuse Policy is a condition of employment. This hospital requires that every newly hired employee be free of drug abuse. I understand and acknowledge that I may be required to submit to a physical examination, including drug testing. I hereby authorize the release of the results of such an examination to Castle Rock Hospital District for their use in evaluating my suitability for employment. Further, I release the examining facility and Castle Rock Hospital District from any and all liability, and from any damage that may result from the release of such information. Each offer of employment is contingent upon successfully completing a urinalysis test/screen for drugs in accordance with hospital policy.
* I UNDERSTAND AND AGREE THAT IF I AM OFFERED EMPLOYMENT BY THE FACILITY, MY EMPLOYMENT WILL BE FOR NO DEFINITE TERM AND THAT EITHER I, OR THE FACILITY WILL HAVE THE RIGHT TO TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, I ALSO UNDERSTAND THAT THIS STATUS CAN ONLY BE ALTERED BY A WRITTEN CONTRACT OF EMPLOYMENT WHICH IS SPECIFIC AS TO ALL MATERIAL TERMS AND IS SIGNED BY ME AND THE ADMINISTRATOR OF THE FACILITY.
Release:
I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my license status and my license history.
Yes I have read and understand these conditions of employment.
Applicant's full name*
Date Prepared
By clicking the "Submit" button below, I agree that all of the preceding questions are answered truthfully and to the best of my abilities.
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