Employment Application

Personal Information

First Name	Last Name
Email Address	Home Phone	Cell Phone
Are you at least 18 years old?	Yes No

Address Information

Current Address
Current City
Current State
Current Zip Code

Previous Address Information

Previous Address
Previous City
Previous State
Previous Zip Code

Employment Information

If overtime work is required periodically, does this pose a problem for you? Yes No

Date available for work *

Have you ever worked in this or any other related facility? Yes No

If yes, what facility?

Are you related to another facility employee? Yes No

Are You Legally Authorized to Work in the United States? Yes No

Application Information

How did you learn about this position?

Are you able to perform the essential, job related functions of the position for which you are applying with or without reasonable accommodations? Yes No

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. Yes No

If yes, give date, place and nature of each such conviction.

Are you presently charged with any violation of the law? Yes No

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? Yes No

Work History

License Information

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 Indicate if any licenses have been revoked, suspended or placed on probation.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.

Current Open Position(s) for which you are applying *
Type of Position	Per Diem Full Time Part Time Pool PRN Temporary
Shift	Day Weekend Evening Night
Salary Requirement
Are you willing to travel?	Yes No	Are you willing to relocate?	Yes No
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?				Yes No

From	To	Company	Phone Number	Supervisor
Salary	Address		May we contact them? Yes No	Name while employed
Job Title		Full Time Part Time PRN		Hours Per Week
Nature of Duties
Reason for leaving

From	To	Company	Phone Number	Supervisor
Salary	Address		May we contact them? Yes No	Name while employed
Job Title		Full Time Part Time PRN		Hours Per Week
Nature of Duties
Reason for leaving

From	To	Company	Phone Number	Supervisor
Salary	Address		May we contact them? Yes No	Name while employed
Job Title		Full Time Part Time PRN		Hours Per Week
Nature of Duties
Reason for leaving

Personal Information

Address Information

Previous Address Information

Position Information

Employment Information

Application Information

Education Information

High School

College

College

Graduate School

Other

Other

Work History

Current or Most Recent

Previous

Previous

License Information

Cascade Family Practice	Cascade Medical Center
402 Lake Cascade Parkway	402 Lake Cascade Parkway
Cascade, Idaho 83611	Cascade, Idaho 83611
208-382-4285	208-382-4242