New Employment Application - Community Health of Central Washington

General Information

Name *

First

Middle

Last

Email *

Phone *

Cell Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Are you authorized to work in the U.S.? *

I am... *

Under the age of 18
Over the age of 18

Do you speak another language besides English?

If yes, what language?

Are you related to a current CHCW employee or Board Member?

If yes, please provide their full name (first and last):

How did you hear about this job opening?

CHCW Website
CHCW Employee
Job Fair
Indeed
WorkSource
Other

If other, please tell us how you learned about this opening:

If you marked "CHCW Employee" please give us the name of the employee:

Have you ever worked at CHCW before?

Have you ever worked for CHCW under another name?

If yes, what was your previous name(s)?

Have you, within the last seven (7) years, been charged or convicted of an offense, or released from prison for an offense involving drugs, narcotics, theft or inflicting bodily injury? *

If yes, please indicate charges, include dates, and summarize circumstances of offense:

Position Information

Desired work site:

CHCW Administration/Residency
CHCW - Ellensburg
Yakima Pediatric Associates
CWFM Clinic
Ellensburg Dental Care
Highland Clinic
Naches Medical Clinic
SRCare
Connect
COVID Clinic

I am interested in:

Full Time
Part Time
Per Diem
Volunteer

Position you are applying for:

Second position you are applying for (if applicable):

Desired wage/salary:

Date you can begin working:

Education Information

High School:

College/University:

Technical Program:

Highest Completed in High School:

GED
Diploma

Highest Completed in College/University:

Two Year
Three Year
Four Year
Degree Pending
Degree

List College Degree(s):

List Technical Program Certification(s):

Additional Skills:

Microsoft Office Suite
Typing
10-Key
Electronic Medical Records
Medical Terminology
Professional License
Other

Please list your other additional skill:

Typing WPM (if applicable):

Professional License Type (if applicable):

List all current and former employers for the last 10 years. Begin with your most recent employer.

Name of Current/Most Recent Employer

May we contact this employer?

Starting Position

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Supervisor

Employment Began

Employment Ended

Reason For Leaving

Position Upon Leaving

Previous Employer

Name of Employer

May we contact this employer?

Starting Position

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Supervisor

Employment Began

Employment Ended

Reason For Leaving

Position Upon Leaving

Previous Employer

Name of Employer

May we contact this employer?

Starting Position

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Supervisor

Employment Began

Employment Ended

Reason For Leaving

Position Upon Leaving

If the job you are applying for asked you to provide a resume, cover letter, or any other document please upload them here. If there is any upload issue please email your documents to hrrecruiter@chcw.org.

Click or drag files to this area to upload. You can upload up to 4 files.

Information Certification/Authorization to Release Information

I certify the information given in the Application for Employment is true and complete to the best of my knowledge. I authorize CHCW to verify my professional licenses and to make inquiry of my former employers or references as to my experience, job suitability and/or reasons for leaving. I understand that if employed, the making of false statements on this Application, or omission of information, will be sufficient cause for my dismissal. Offers of employment are contingent upon satisfactory references from former employers and colleagues. I further understand that after receiving an offer of employment, I will be required to take a drug test and my actual employment may be conditional upon the results of this examination. I agree to hold harmless CHCW and any company and/or individual(s) for information they may release with regards to this Application. I understand that my employment is contingent upon proof of identity and verification of eligibility for employment in the United States. I also understand that my employment is contingent upon a satisfactory criminal history background check. I understand that this Application, singularly or together with other CHCW documents or policies, does not create a contract of employment. I also understand that if hired, I may voluntarily resign or be terminated at any time for any reason. If I accept a position at CHCW, I agree to comply with all its policies and procedures. In the event of termination of employment with CHCW, I agree to return all CHCW property (such as keys, ID badge, etc.). *

I agree
I do not agree