North Star Behavioral Health System

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Online Job Application

Job Application
(PDF format)

Online Job Application

APPLICATION FOR EMPLOYMENT

PRE-EMPLOYMENT DRUG SCREEN IS REQUIRED.

Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, or disability.

Date of Application:

Position Applied For:

(If Nursing, what department)

Referral Sources: Print Advertisement Website/Electronic Job Board

Employment Agency Friend Walk-In

Relative

Name and Relationship of Relative

Other

FIRST NAME:

LAST NAME:

LICENSURE:

DATE ACQUIRED:

ADDRESS:

CITY:

STATE:

ZIP:

TELEPHONE:

SOCIAL SECURITY

NUMBER:

Can you furnish a work permit if you are under 18? Yes No N/A

Have you filed an application here before? Yes No

If Yes, give date

Have you ever been employed here or at another UHS Facility? Yes No

If Yes, when, where?

Do you have any relatives currently employed here? Yes No

Are you employed now? Yes No

May we contact your present employer? Yes No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?

(Proof of citizenship or immigration status is required upon employment.)

Yes No

Minimum Salary Requirements:

On what date are you available for work?

Are you available to work Full-Time Part-Time Per Diem Temporary Weekends

Shift: 1st 2nd 3rd 7am - 7pm, where available 7pm - 7am, where available

Are you on a lay-off and subject to recall? Yes No

Can you travel if a job requires it? Yes No

Have you ever been convicted of a crime? Yes No

(Conviction does not necessarily disqualify applicant from employment)

Have you ever had your professional license suspended or revoked?

Yes No Not applicable

Veteran of U.S. Military Service? Yes No

If yes, Branch

HIGHEST EDUCATION LEVEL ACHIEVED:

(include type of degree where applicable):

High School Graduate

2 Year College; Associate Degree

Bachelor's Degree

Master's Degree

Other (please specify):

SKILLS, TRAINING, ETC.

(describe specialized training, apprenticeship, skills with number of years experience. Describe extra-curricular activities.)

State any additional information you feel may be helpful to us in considering your application

The primary requirement of most positions is English.

(Optional) Indicate any other languages you speak, read and/or write:

List professional, trade, business or civic activities and offices held. (You may exclude those which indicate race, color, religion, sex or national origin):

EMPLOYMENT EXPERIENCE: Indicate any other name under which you have worked.

(Past three positions - include employer name address and phone number, position, title, supervisor name, dates of employment, reason for leaving and starting and ending salary)

Applicant's Certification and Agreement

(Please Read Carefully)

In consideration of being employed, I understand and agree that:

1. If I misrepresent or deliberately leave out a fact in my application, I may be refused

employment or, if employed, I may be terminated.

2. The employer has my authorization to thoroughly investigate my work and personal and credit

history and I hereby consent to take any test, whenever the employer deems it necessary in

any employer investigation. I will hold no person, corporation or organization liable for giving

or receiving information in such investigation.

3. If employed, I may terminate my employment at any time without notice or cause, and the

employer may terminate or modify the employment relationship at any time without prior

notice or cause. In consideration of my employment, I agree to conform to the rules and

regulations of the employer, and I understand that no department head or representative of

the employer, other than the President of the Company, has any authority to enter into any

agreement or assurances contrary to this policy.

4. Any doctor, hospital or testing laboratory has my consent to conduct medical or drug test on

me, and I hereby give my consent to having all information released for the employer to

determine my abilities to perform job duties now or in the future. I also give my consent to

physical searches of myself and my brief case, lunch box, car, locker or any packages or

purse I have while on the employer's premises whether or not I have a lock on such items.

5. The needs of the employer may make the following conditions mandatory: overtime, shift

work, rotating work schedule, or a work schedule other than Monday through Friday. I

accept these conditions of employment.

6. The employer is an equal opportunity employer. The employer does not discriminate in

employment and no question on my employment application is used for the purpose of limiting

or excluding any applicant's consideration for employment on a basis prohibited by local,

state or federal law.

7. If employed, I understand that my employment is for no definite period of time, and if

terminated, the employer is liable only for wages or salary earned as of the date of

termination.

8. I understand that the employer requires all staff to report sanction, convictions, suspensions,

censures or revocation ("sanction") action taken against them by federal, state, local or other

professional licensure, criminal history convictions, history of child abuse, managed care

organizations, etc.

9. This application is current and active for only six months. At the conclusion of this time, if I

have not had any contact from the employer and still wish to be considered for employment,

it will be necessary for me to fill out a new application.

10. If employed, I understand that I must abide by the Company's established Service Excellence

standards and realize that Service Excellence is a priority of the Company.

I have read and agree to the above and hereby certify that the facts I have provided in my employment application are true and complete.

I Agree I Disagree

Hospital & Residential Treatment Centers • Anchorage: DeBarr · Bragaw; Palmer
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