Statement to Applicant:  Pleasant Valley Hospital is delighted that you have chosen to apply for employment with Pleasant Valley Hospital.  Before proceeding to complete this application, please read and carefully consider the following statements regarding Pleasant Valley Hospital's employment policy.

Equal Opportunity Employer:  Pleasant Valley Hospital is firmly committed to providing equal employment opportunity to all persons.  Job applicants and employees shall not be discriminated against based on their race, color, religion, sex, age, national origin, disability, ancestry or veteran status.  Pleasant Valley Hospital's hiring decisions are based on the most qualified, competent individuals for all positions, along with experience and references.

At-Will Employment Policy:  Pleasant Valley Hospital is an at-will employer.  If you are hired, you will be free to leave Pleasant Valley Hospital's employment at any time for any reason.  Correspondingly, while Pleasant Valley Hospital hopes to have a long and productive work relationship with its employees, it reserves the right to separate an employee from its work force without notice at any time.

Smoke-Free Work Environment:  Pleasant Valley Hospital employees are prohibited from smoking while on duty in the Hospital.  If you would not be completely comfortable working for an employer with these policies, you should not further pursue employment with Pleasant Valley Hospital.

	Personal Information Full Name: * E-mail: * Telephone Number: * Social Security Number: Are You A United States Citizen? * Yes No Current Address: * Living There Since * Previous Address: Lived There Beginning: Ending: Person To Be Notified In Case Of Emergency: * Relationship To Person: Telephone Number To Reach Them: * Address Where Person Can Be Reached: Have You Served In The U.S. Armed Services? * Yes No Branch: Highest Rank: Date Service Began: Ended: Area Of Specialty: Do You Smoke? * Yes No Have You Ever Been Convicted Of Any Criminal Violation Of Law? * Yes No If Yes, Please Explain: Any Action(s) By A Duly Authorized Federal Or State Agency For Conduct Or Performance Against You? * Yes No If Yes, Please Explain: List Any Relatives Currently Working For the Hospital: Employment Information Applying For Position: * A Job Description Will Be Provided At The Time Of The Interview For This Position. Requested Salary: Per: Year Month Week When Can You Start? * What Employment Conditions Are You Willing To Accept? (Select All That Apply) * Weekend Work Holiday Work Full-Time Work Part-Time Work Day Shift Evening Shift Night Shift Rotating Shifts Permanent Work Temporary Work Summer Work Do You Have Adequate Transportation? * Yes No Additional Experiences, Skills Or Qualifications Which May Be Applicable To Work At The Hospital: Professional License(s) Or Registration: Occupation: State: State Number: National Number: Education Name of High School: * Address: Course Of Study: Years Completed: Did You Graduate? * Yes No _____________________________________________________ Name Of College: Address: Course Of Study: Years Completed: Did You Graduate? Yes No Credits Diploma or Degree/Year: _____________________________________________________ Other School: Address: Course Of Study: Years Completed: Did You Graduate? Yes No Credits Diploma or Degree/Year: Present And Previous Employment Name Of Most Recent Employer: Are You Currently Employed There? Yes No May We Contact Your Present Employer? Yes No Address: Telephone Number: Type Of Business: Name Of Supervisor: Briefly Summarize Experience Gained: Position(s) Held (Specify If Part-Time): Highest Salary At Each Position: Worked There Beginning: Ending: Reason(s) For Leaving: _____________________________________________________ Name Of Previous Employer: Address: Telephone Number: Type Of Business: Name Of Supervisor: Briefly Summarize Experience Gained: Position(s) Held (Specify If Part-Time): Highest Salary At Each Position: Worked There Beginning: Ending: Reason(s) For Leaving: _____________________________________________________ Name of Previous Employer: Address: Telephone Number: Type Of Business: Name Of Supervisor: Briefly Summarize Experience Gained: Position(s) Held (Specify If Part-Time): Highest Salary At Each Position: Worked There Beginning: Ending: Reason(s) For Leaving: Personal References Reference #1 Name: * Telephone Number: * Address: Occupation: Number Of Years Acquainted: * _____________________________________________________ Reference #2 Name: Telephone Number: Address: Occupation: Number Of Years Acquainted: _____________________________________________________ Reference #3 Name: Telephone Number: Address: Occupation: Number Of Years Acquainted: _____________________________________________________ Reference #4 Name: Telephone Number: Address: Occupation: Number Of Years Acquainted: _____________________________________________________ Cover Letter: Upload Resume _____________________________________________________ I understand I will be fingerprinted for Criminal Background Investigation. I certify that all of the information I have supplied on this application is complete and true, and understand that any omission or misrepresentation of fact may result in refusal or separation from employment. I authorize all former employers to furnish any information concerning my service. my reason for leaving their employment and any other information they may have on my record. I also release any individual, partnership, or corporation which formerly employed me, its officers, agents and employees, from liability for any damage due to issuing such information. I agree that I must successfully complete all aspects of a pre-employment screening, including a post-offer/pre-employment physical examination, to be eligible for employment. I agree to conform to the rules and regulations of the Pleasant Valley Hospital. I understand that, if hired, Pleasant Valley Hospital nay terminate my employment at any time, for any reason with or without notice. I further understand that no employee or representative of Pleasant Valley Hospital has the authority, at the present or future, to promise me any benefit, oral or written, without the approval of the Executive Director or Director of Human Resources of Pleasant Valley Hospital, who has the authority to enter into contracts and/or make promises only if in writing.   I Have Read And Fully Understand The Terms Described Above. * Yes, I Understand.