William Bee Ririe Critical Access Hospital and Rural Health Clinic
Keeping you and your family safe.
William Bee Ririe Hospital Secure Employment Application

Human Resources Department
1500 Avenue H
Ely, Nevada 89307
979-921-9853
It is the policy of this facility to provide equal opportunity to persons regardless of race, religion, age, gender, disability, veteran status or other classification in accordance with federal, state, and local statutes, regulations, and ordinances.
This application can be active as long as legally required.
Last NameFirst NameM.
Are you at least 18
years old?
SSN
Phone
Present Address
Present City
Present State
Present Zipcode
Email Address
Permanent Address
Permanent City
Permanent State
Permanent Zipcode
Current Open Position(s) for which you are applying



Type of Position
Per DiemPool
Full TimePRN
Part TimeTemporary
Shift
 Weekend
DayNight
EveningRotation
Salary Requirement
$
Are you Willing
to Travel?
Are you Willing
to Relocate?
Do you have adequate means of transportation to get to work on time
each day and when called in on short notice during normal working hours?
If overtime work is required periodically,
does this pose a problem for you?
Date Available for Work
Are You Legally Authorized
to Work in the U.S.?
Have you ever worked in this
or any other facility?
If yes, what facility
Are you related to another
facility employee?
How did you learn about this position?

State Employment Commission
Internet
Agency
Ad
Job Listing
School
Current Employee
Job Line
Other
Are you able to perform the essential, job related functions of the position for which
you are applying with or without reasonable accommodations?
Describe any accommodations necessary:
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.)(NRS 449.174 within 7-years)
If yes, give date, place and nature of each such conviction.
Are you presently charged with any violation of the law?
If yes, give date, place and nature of each such event:
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?
Educational History
Type of School
Name of School
City, State
Check Last Year Attended in SchoolDegree or Certificate
High School
School:
City, State: ,
9 10 11 12
Graduated/GED?
Degree:
College
School:
City, State: ,
1 2 3 4
Graduated?
Degree:
College
School:
City, State: ,
1 2 3 4
Graduated?
Degree:
Graduate School
School:
City, State: ,
1 2 3 4
Graduated?
Degree:
Other
School:
City, State: ,
1 2 3 4
Graduated?
Degree:
Other
School:
City, State: ,
1 2 3 4
Graduated?
Degree:
Please describe any honors received, volunteer work, community service, or other qualifications which my pertain to the job you are applying for.
Have you ever been a member of the
United States Military?
If yes, what branch did you serve in?
What was the dates of your duty?
to
What was your rank at discharge?
List any professional licenses, registration or certification you possess (Include Driver's License, if applicable)
  • Include Type, State Issued, Expiration Date and Number
  • Indicate if any licenses have been revoked, suspended or placed on probation.
  • Also indicate if you are ineligible to become licensed or certified in your field. Please explain.
Clerical or other skills applicable to the position for which you are applying.
Typing   (WPM)
PBX
Proficient in Software:
Business machines and/or equipment you can operate:
Other  
Work History (HR7940 Rev 07/02)
Current or Most Recent
From (MM/YYYY)
/
To (MM/YYYY)
/
Company
Phone No.
Immediate Supervisor
Salary
$
Address
May we contact them?
Name while employed
Job Title
Employment Type

PRN
Full-Time
Part-Time hrs/week
Reason for Leaving
Nature of Duties
1st Previous
From (MM/YYYY)
/
To (MM/YYYY)
/
Company
Phone No.
Immediate Supervisor
Salary
$
Address
May we contact them?
Name while employed
Job Title
Employment Type

PRN
Full-Time
Part-Time hrs/week
Reason for Leaving
Nature of Duties
2nd Previous
From (MM/YYYY)
/
To (MM/YYYY)
/
Company
Phone No.
Immediate Supervisor
Salary
$
Address
May we contact them?
Name while employed
Job Title
Employment Type

PRN
Full-Time
Part-Time hrs/week
Reason for Leaving
Nature of Duties
3rd Previous
From (MM/YYYY)
/
To (MM/YYYY)
/
Company
Phone No.
Immediate Supervisor
Salary
$
Address
May we contact them?
Name while employed
Job Title
Employment Type

PRN
Full-Time
Part-Time hrs/week
Reason for Leaving
Nature of Duties
Please list any professional organizations in which you are a member.
If your former employment references, education, or military service are under a name other than indicated on front of application, please indicate that name.
Professional References (Other than Relatives) Give references who have good knowledge of your work.
NamePositionAddress, City, StatePhoneNumber of
Years known
, ,
, ,
, ,
, ,
Please Review and Acknowledge That You Understand The Following.
In making 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 or any affiliate. 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 or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.

• I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable. If such an investigative report is made, I understand that I will receive notice that such a report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.

I UNDERSTAND AND AGREE THAT ANY EMPLOYEE HANDBOOK WHICH I MAY RECEIVE WILL NOT CONSTITUTE AN EMPLOYMENT CONTRACT, BUT WILL BE MERELY A GRATUITOUS STATEMENT OF FACILITY POLICIES.

• I understand that the facility reserves the right to require its employees to submit to blood tests or urinalyses for alcohol or drug screens, or to allow inspection of bags (including purses or briefcases) or parcels brought into or taken out of the facility. I understand that refusal to submit to a urinalysis or blood test, when requested to do so, may result in termination of my employment.

• Compliance with this facility's Substance Abuse Policy is a condition of employment. This hospital requires that every newly hired employee be free of alcohol or drug abuse. Each offer of employment is contingent upon successfully completing a urinalysis test/screen for alcohol and drugs in accordance with hospital policy. Continued employment is also contingent upon compliance with the hospital's Alcohol and Drug Abuse 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 licensure status and my licensure history.

I agree that I will settle any and all claims, disputes or controversies arising out of or relating to my application for employment, employment or termination of employment with the employer exclusively by final and binding arbitration and before a neutral Arbitrator and in accordance with the rules and procedures for employment disputes adopted by the employer.  Such claims shall include those that could be brought in a court of law under any applicable federal, state or local statutory or common law, such as the Age Discrimination in Employment Act, Title VII of the Civil Rights Act of 1964, as amended, including the amendments of the Civil Rights Act of 1991, the Americans with Disabilities Act, the Family and Medical Leave Act, state civil rights acts, the law of contract and the law of tort.
This employer participates in E-Verify. E-Verify is a service of the U.S. Department of Homeland Security and the Social Security Administration. Federal Law Requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States. This employer will provide the Social Security Administration (SSA) and, if necessary, the Department of Homeland Security (DHS), with information from each new employee's Form I-9 to confirm work authorization. Important: If the government cannot confirm that you are authorized to work, this employer is required to provide you written instructions and an opportunity to contact SSA and/or DHS before taking adverse action against you, including terminating your employment. Employers may not use E-Verify to pre-screen job applicants or to re-verify current employees and may not limit or influence the choice of documents presented for use on the Form I-9. In order to determine whether Form I-9 documentation is valid, this employer uses E-Verify's photo screening tool to match the photograph appearing on some permanent resident and employment authorization cards with the official U.S. Citizenship and Immigration Services' (USCIS) photograph. If you believe that your employer has violated its responsibilities under this program or has discriminated against you during the verification process based upon your national origin or citizenship status, please call the Office of Special Counsel at 1-800-255-7688 (TDD: 1-800-237-2515). For more information on E-Verify please contact DHS at: 1-888-464-4218
Este empleador participa en E-Verify. E-Verify es un servicio del Departamento de seguridad nacional de Estados Unidos y la administración de la Seguridad Social. La Ley Federal le exige a todos los empleadores que verifiquen la identidad y elegibilidad de empleo de toda persona contratada para trabajar en los Estados Unidos. Este empleador le proporcionará a la Administración del Seguro Social (SSA), y si es necesario, el Departamento de Seguridad Nacional (DHS), información obtenida del Formulario I-9 correspondiente a cada empleado recién contratado con el propósito de confirmar la authorization de trabajo. Importante: En dado caso que el gobierno no puede confirmar si está usted autorizado para trabajar, este empleador está obligado a proporcionarle las instrucciones por escrito y darle la oportunidad a que se ponga en contacto con la oficina del SSA y, o el DHS antes de tomar una determinación adversa en contra suya, inclusive despedirlo. Los empleadores no pueden utilizar E-Verify con el propósito de realizar una preselección de aspirantes a empleo o para hacer nuevas verificaciones de los empleados actuales, y no deben restringir o influenciar la selección de los documentos que sean presentados para ser utilizados en el Formulario I-9. A fin de poder determinar si la documentación del Formulario I-9 es valida o no, este empleador utiliza la herramienta de selección fotográfica de E-Verify para comparar la fotografía que aparece en algunas de las tarjetas de residente y autorizaciones de empleo, con las fotografías oficiales del Servicio de Inmigración y Ciudadanía de los Estados Unidos (USCIS). Si usted cree que su empleador ha violado sus responsabilidades bajo este programa, o ha discriminado en contra suya durante el proceso de verificación debido a su lugar de origen o condición de ciudadanía, favor ponerse en contacto con la Oficina de Asesoría Especial llamando al 1-800-255-7688 (TDD: 1-800-237-2515). Para mayor información sobre E-Verify, favor ponerse en contacto con la oficina del DHS llamando al: 1-888-464-4218
I have read and understand these conditions of employment. Yes
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.

   

Clinic Appointments
775.289.4040
Customer Service
775.289.3612 Ext. 346
Central Billing
775.289.3467 Ext. 228/233
WILLIAM BEE RIRIE
Critical Access Hospital
1500 Avenue H
Ely, Nevada 89301
775.289.3001
WILLIAM BEE RIRIE
Rural Health Clinic
6 Steptoe Circle
Ely, Nevada 89301
775.289.3612
© 2018 William Bee Ririe Critical Access Hospital and Rural Health Clinic