PMHNP Resident Employment Application

PMHNP Resident Employment Application

P.O. Box 960 | Bremerton, WA 98337

Administrative Office [360] 475-6706 | Fax [360] 373-2096

Email: hrassistants@pchsweb.org

Last*

First*

MI

Date*

Date

Street Address*

Apartment

City*

State*

Zip Code*

Phone*

Email*

example@example.com

Do you have any immediate family members or any relatives currently working for PCHS?*

YesNo

Name(s) of family member/relative:

1. Can you provide documentation which authorizes you to work in the Unites States?*

YesNo

2. Have you been on the Office of Inspector (OIG) list of excluded individuals?*

YesNo

If you answered "yes" to #2, please explain:

How did you learn of this position? Please specify below.

Online/Job Posting

Newspaper

PCHS Website

Walk-In

Other

Other (Name/Source)

PCHS Employee

PCHS Employee Name:

EDUCATION Your name used while attending school if different from above.

First Name

Last Name

Middle Initial

Name of High School Attended*

City State

Graduate*

YesNo

If Yes, what year?

G.E.D.?

YesNo

Name of Colleges/Universities Attended:*

Major*

Dates Attended: (Mo/Yr)

From*

To*

Degrees Conferred*

YesNo

Name of Colleges/Universities Attended:

Major

Dates Attended: (Mo/Yr)

From

To

Degrees Conferred

YesNo

Technical Institute/Business Attended:

Dates Attended: (Mo/Yr)

From

To

Degrees Conferred

YesNo

SKILLS (List any vocational or on-the-job training you have completed; any special training you have completed; and any special license(s) or certification(s) which are necessary or useful.)*

License Certificate or Registration*

State Issued*

Number*

Expiration Date

Date

License Certificate or Registration

State Issued

Number

Expiration Date

Date

Are you proficient in any languages other than English? (If Yes, list them below.)*

YesNo

Language type (# of years for R/W/S)
1) LANGUAGE READ WRITE SPEAK

EXPERIENCE List all work experience, including relevant volunteer experience.

Employed by:*

Job Title:*

Address:*

City & State:*

Employed (Mo/Yr) From:*

To:*

Supervisor:*

Phone:*

May we contact?*

YesNo

Average Hours/Week:

End Salary:

$

Your Duties

Reason for leaving

Employed by:

Job Title:

Address:

City & State:

Employed (Mo/Yr) From:

To:

Supervisor:

Phone:

May we contact?

YesNo

Average Hours/Week:

End Salary:

$

Your Duties

Reason for leaving

Employed by:

Job Title:

Address:

City & State:

Employed (Mo/Yr) From:

To:

Supervisor:

Phone:

May we contact?

YesNo

Average Hours/Week:

End Salary:

$

Your Duties

Reason for leaving

Do you believe you are capable of performing the essential functions of the job, with or without reasonable accommodation for which you are applying for?*

YesNo

If you require any accommodation during the application testing or interview process you may note them here if you wish:

AUTHORIZATION AND CERTIFICATION

I certify that to the best of my knowledge and belief, the answers given by me to the questions and the statements made in my application materials are true, complete and written solely by me. Should I be accepted for employment, I understand that any false or inaccurate information contained in my application materials may result in immediate discipline, up to and including termination of employment.

I authorize Peninsula Community Health Services (PCHS) and/or its agents to conduct background investigations of my personal history, including current and past employment. This research may include, but is not limited to information obtained from employers, persons named as references, licensing departments, school officials, etc. Should PCHS first offer me employment that is conditioned upon the results of a "criminal background check, I hereby authorize PCHS to perform such a criminal background check on me and I also agree to provide PCHS with "criminal history record information, if so asked by PCHS. I release all parties providing such information from any liability for any loss or damage whatsoever resulting from providing such information. A photocopy, fax, or other kind of electronically transmitted copy of this certificate will be considered equally valid as the signed original.

I understand that if I have ever worked for PCHS through a temporary placement services agency, I will be fully responsible for paying any and all agency fees that may apply for the position I accept with PCHS.

I understand that if I am hired, I will be required to provide proof of identity, legal work authorization, and a copy of my degree and/or certification.

I understand that employment at PCHS is "at will," which means that either I or PCHS can terminate employment for any reason not prohibited by law. I understand that no supervisor, manager, director or other representative of PCHS has any authority to alter the foregoing, except the Chief Executive Officer, who may do so in writing.

Signature*

Date*

Date

Applicants must submit the following in addition to the PCHS Resident Employment Application:

1. Personal Statement addressing the following in 1,000 words or less.

a. Why are you choosing a residency at Peninsula Community Health Services?

b. Please describe your experience working with under-served and vulnerable populations.

c. What are you hoping to achieve through a residency in psychiatry – what are your career goals?

Personal Statement

2. A copy of your Curriculum Vitae (CV)

Curriculum Vitae (CV)

3. Three (3) letters of recommendation:

One professional

One academic

One of your choice

Letters of recommendation:

4. ARNP transcript

ARNP transcript

5. ARNP Diploma and Certifications

Diploma and Certifications

6. Washington State License

Washington State License

Should you have any questions, please submit them to:

hrassistants@pchsweb.org

LANGUAGE FLUENCY

JOB REQUIREMENTS

SUPPLEMENT TO THE RESIDENT EMPLOYMENT APPLICATION