Apply Now – Northern Wyoming Surgical Center

Employment Application

Thank you for your interest in a position at Northern Wyoming Surgical Center.

Northern Wyoming Surgical Center is a full-service ambulatory (outpatient) surgical, endoscopy and pain management center. We provide the highest quality services for outpatients in a comfortable, convenient and cost competitive setting. Our board-certified physician staff and certified advanced practice professionals have years of experience in surgical procedures and is committed to providing high-quality, safe patient care. Our commitment to our patients and the Big Horn Basin Community is a priority and allows us to provide the latest techniques in surgical procedures. Providing the best care starts with our staff.

Northern Wyoming Surgical Center is committed to recruiting and retaining the best people available while maintaining a safe and high quality staff-to-patient ratio.

To ensure the timely processing of your application, please note the following:

• Incomplete applications will not be accepted.

• Type clearly in full sentences.

• If submitting a resume, an official application must also be completed.

Upon close of the recruitment period, all applications will be reviewed to determine if the minimum qualifications for the position have been met. If you are selected for an interview, you will be contacted by phone. After all interviews have taken place and an applicant has accepted the position, remaining applicants will be contacted and informed that the position has been filled.

We thank you for your interest in the applicable position and wish you the best of luck.

Name: *

First

Last

Date of Application: *

Address: *

Phone Number: *

Email: *

Date Available: *

Desired Salary: ($) *

Position Applied for: *

Do you have a current BLS (CPR) certificate? *

If RN, do you have a current ACLS? *

Are you a current US citizen? *

Have you ever worked for our company before? *

If yes, when?

Have you ever been convicted of a felony? *

If yes, please explain:

High School: *

Address: *

Dates Attended: *

Did you graduate? *

Diploma: *

College: *

Address: *

Dates Attended: *

Did you graduate? *

Degree: *

Other Education:

Address:

Dates Attended:

Did you graduate?

Degree:

Other Education:

Address:

Dates Attended:

Did you graduate?

Degree:

Reference Name #1: (First & Last) *

Relationship: *

Company: *

Phone Number: *

Address: *

Reference Name #2: (First & Last) *

Relationship: *

Company: *

Phone Number: *

Address: *

Reference Name #3: (First & Last) *

Relationship: *

Company: *

Phone Number: *

Address: *

Previous Employer #1: *

Phone Number: *

Address: *

Supervisor: *

Job Title: *

Starting Salary: ($) *

Ending Salary: ($) *

Responsibilities: *

Dates Employed: *

Reason for Leaving: *

May we contact your previous supervisor as a reference? *

Previous Employer #2: *

Phone Number: *

Address: *

Supervisor: *

Job Title: *

Starting Salary: ($) *

Ending Salary: ($) *

Responsibilities: *

Dates Employed: *

Reason for Leaving: *

May we contact your previous supervisor as a reference? *

Previous Employer #3: *

Phone Number: *

Address: *

Supervisor: *

Job Title: *

Starting Salary: ($) *

Ending Salary: ($) *

Responsibilities: *

Dates Employed: *

Reason for Leaving: *

May we contact your previous supervisor as a reference? *

Are you a member of the military? *

Branch:

Dates of Service:

Rank at Discharge:

Type of Discharge:

If other than honorable, explain:

Signature: *

I understand and certify that all information supplied in this application is complete and correct. Any false, misleading, or incomplete information furnished by me regarding this application may result in the rejection of this application or if employed, dismissal. I understand that in consideration of my employment, I agree to conform to the rules and regulations of the company, and further agree that my employment and compensation are at the will of the company and can be terminated, with or without cause, and with or without notice at any time at the option of either the company or myself. I understand and hereby authorize all persons, schools, companies, employers and /or their representatives to furnish verification to Northern Wyoming Surgical Center (NWSC), its representatives or agents, any and all information set forth in this application. In addition, I hereby agree to hold harmless and to release from all liability all said persons, schools, companies, employers and /or their representatives from any and all claims that I may have, or which may arise, against any and /or all of them, including the company as a result of them furnishing information to NWSC. I authorize NWSC, should they employ me, to release employment references, if my employment becomes terminated for any reason. I also authorize NWSC to conduct credit, police, criminal and driving record inquiries, or any other employment related inquiries in compliance with the provisions of the Fair Credit Reporting Act, 15 U.S.C. Section 1681, et. seq. I understand that the decision to hire me and my continued employment will be subject to the results of these inquires and are dependent upon successful completion of a criminal background check, urine drug and alcohol screen, TB and physical assessments. NWSC is an equal opportunity employer. No question on this 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. NWSC has a firm commitment to its employees, customers, and the public to provide the safest and most competent services possible. The nature of our business requires that we promote high standards of employee health. Therefore, any employee sustaining an on-the-job injury that requires medical treatment or that involves damage to NWSC property may be requested to submit to a blood and /or urine test to determine the possible presence of drugs and /or alcohol. Any employee guilty of serious safety infractions, including near-miss situations, or failure to follow established safety procedures may be subject to testing under this policy. I understand this application will be active for employment consideration for 90 days. I have read, understand, and agree with the above statements as delineated above. DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Date: *