Riverwood Surgery Center - Utah County's Premier Surgery Center




	Employment Application (AN EQUAL OPPORTUNITY EMPLOYER)


		Name (as it appears on your social security card)


		Preferred Name (Last, First, Middle)


	Present Address (Street, City, State, Zip)


	Permanent Address (if different from present address)


		eMail Address


			Social Security Number


		Home Telephone Number


		Work Telephone Number


		Cell Phone Number


	Position Desired


		Date Available


		Are you over 18 years of age?


	Desired Wage


	Yes


	No


	Full-Time


	Part-Time


	If under 18, what is your birthdate?


	PRN


	Do you have a permanent unrestricted right-to-work in the U.S.A.?


	Yes


	No


	If yes, what is your visa status and expiration date?


	Please list most recent experience first

		Name of Employer


	Address (street, city, state, zip)


		Company Phone Number


	Title or Position


	Supervisor Name & Position


	Can we contact as a reference?


	Yes


	No


	From: (mm/dd/yy)


			Starting Wage


			Major Duties


		To: (mm/dd/yy)


	Ending Wage


	Reason for Leaving


	Name of Employer


	Address (street, city, state, zip)


		Company Phone Number


		Title or Position


		Supervisor Name & Position


	Can we contact as a reference?


	Yes


	No


		From: (mm/dd/yy)


		Starting Wage


		Major Duties


	To: (mm/dd/yy)


	Ending Wage


		Reason for Leaving


	Name of Employer


	Address (street, city, state, zip)


	Company Phone Number



		Title or Position



	Supervisor Name & Position


	Can we contact as a reference?


	Yes


	No


		From: (mm/dd/yy)



		Starting Wage



		Major Duties


	To: (mm/dd/yy)



		Ending Wage


	Reason for Leaving


	Organization



	Major Duties, Positions Held


	From: (mm/dd/yy)


		To: (mm/dd/yy)


	Organization



		Major Duties, Positions Held


	From: (mm/dd/yy)


		To: (mm/dd/yy)


	In addition to current/former employers, please list 3 professional references not related to you whom we can contact:


	Name



		Company


		Relationship



	Title


	How long have you known?


		Address (street, city, state, zip)


		eMail


Name



	Company



		Address (street, city, state, zip)


		Relationship



		Title


	How long have you known?

		eMail


	Name



		Company



	Address (street, city, state, zip)


	Relationship



	Title


	How long have you known?

		eMail


		Name of HIGH SCHOOL



		Address (street, city, state, zip)


	No of Years Completed


	Degrees Acquired


		Name of COLLEGE, UNIVERSITY OR trADE/VOCATIONAL SCHOOL



	Address (street, city, state, zip)


		No of Years Completed


	Degrees Acquired


	Name of COLLEGE, UNIVERSITY OR trADE/VOCATIONAL SCHOOL



		Address (street, city, state, zip)


	No of Years Completed


		Degrees Acquired


	Type of License/Certificate


		State Issued


		Date Issued (mm/dd/yy)


	Date Expires (mm/dd/yy)


	Type of License/Certificate


	State Issued


	Date Issued (mm/dd/yy)


	Date Expires (mm/dd/yy)


	Type of License/Certificate


		State Issued


	Date Issued (mm/dd/yy)


	Date Expires (mm/dd/yy)


	1. Have you ever pled guilty to, been convicted of, or received probation, deferred adjudication or pre-trial diversion for any criminal offense other than minor traffic violations?


	Yes


	No


	If yes, provide information on criminal offense, date, location (city and state) and disposition


	2. Have you ever had a nursing license or other professional license in any jurisdiction limited, suspended, revoked or partially relinquished?


	Yes


	No


	If yes, provide details


	I certify that all information given on this application is true, correct and complete to the best of my knowledge. I understand that discovery of any misrepresentation or omission of fact will make me ineligible for employment or be the cause for immediate dismissal.


	I authorize any inquiry to be made on any information contained in this application if I am considered for employment. I voluntarily consent to the release by my former educators or employers of any information or records requested by Riverwoods Surgery Center. I will hold no person or organization liable for giving or receiving information in any investigation.

If employed by Riverwoods Surgery Center, I agree to abide by its rules and regulations. I understand that my employment is subject to a successful completion of a pre-employment physical examination that may include a drug screen and that my continued employment may be conditioned upon maintaining a favorable health evaluation. If requested, I agree to submit, at any time, to a physical examination, performed by a qualified medical doctor selected by Riverwoods Surgery Center.


	I understand that this is an application for employment and that no employment contract is being offered. I further understand that if employed, such employment is at-will for an indefinite period and can be terminated by either party with or without notice at any time for any reason, and is subject to changes in wages, conditions, benefits and operating policies.


	APPLICANT SIGNATURE




		(completing this field will be deemed a valid signature whether by actual signature or completing the field electronically)


	DATE


	(mm/dd/yy)


	*Please proofread your application thoroughly before clicking on the “Submit” button*