Secure Application for Employment
Human Resources
1100 Carson Ave
La Junta, CO 81050
Arkansas Valley Regional Medical Center provides employment opportunities to all qualified applicants
without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity or expression,
pregnancy, medical condition related to pregnancy, creed, ancestry, national origin, marital status,
genetic information, or military status (with preference given to military veterans), or any other protected status
in accordance with applicable law.
http://www.avrmc.org
email:  hr@avrmc.org
Date
This application can be active as long as legally required.
Last Name                                    First Name                                  Middle Initial
   
Are You At Least 18 Years Old?

Last 4-digits of
Social Security Number

Home Phone And Cell Phone

Address

City

State

Zip Code

E-Mail Address

Current Open Position(s) for Which You Are Applying



Type of Position
Full Time
PRN
Part Time
Shift

Weekend
Day
Night
Evening
Rotation
Date Available For Work

Are You Legally Authorized to Work in the U.S.?
Have you ever been employed by Arkansas Valley Regional Medical Center?
If yes, indicate dates: Are you related to another facility employee?
How did you learn about this position?
Newspaper
AVRMC Website
Colorado Workforce
School
LinkedIn
Indeed
Current Employee
Who?
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:
Educational History
Type of School
Name of School

City, State
Date Obtained
Degree or Certificate
High School
School:
    City:
   State:


Degree:
College
School:
    City:
   State:


Degree:
College
School:
    City:
   State:

Degree:
Graduate
School

School:
    City:
   State:

Degree:
Other
School:
    City:
   State:

Degree:
Other
School:
    City:
   State:

Degree:
List any professional licenses, registration or certification you possess
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Indicate if any licenses have been revoked, suspended or placed on probation.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