Secure Application for Employment
Human Resources Department
440 West Laurel Avenue
Plentywood, Montana 59254
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.                                                                                       
http://smhmt.fasthealth.com
email: 
Date
This application can be active as long as legally required.
Last Name                                    First Name                                  Middle Initial
   
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
Temporary
Shift Available

Weekend
Day
Night
Evening
Rotation
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 for Sheridan Memorial?
If yes, when? Are you related to another SMHA employee?
How did you learn about this position?
SMHA Website
Facebook
Indeed
Job Service
Newspaper
SMHA Employee Referral
Which SMHA employee referred you, if any?
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.
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 School

Degree 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:
LICENSES & CERTIFICATIONS

Professional Licensure

Type of License/Certification State License Number Issued Expires Temp / Perm
Is your licensure/certification/currently active and in good standing? Yes No N/A
Are you aware of any pending actions against your licensure? Yes No N/A
Have any of your licenses/certifications been or are currently in the process of being voluntarily or involuntarily relinquished, denied, revoked, suspsended, reduced, limited, placed on probation, not renewed, or subjected to professional reprimand or other disciplinary action? Yes No N/A
Are you licensed in any other state? Yes No N/A
If yes, please list:
Are you currently on the excluded list from the Office Inspector General (OIG)? Yes No
SKILLS / EXPERIENCE

Check all that apply

Typing (speed/accuracy)
10-Key Adding Machine (speed)
Switchboard
Medical Terminology
Cerner
Lawson Financial
Word
Excel

Other special training or skills not mentioned
above (if applicable):

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