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Employment Application

So you're interested in a career here at the Lompoc Valley Medical Center? Well just sit back, grab cool beverage and take a moment to fill out our online-application. Be sure to not leave any fields blank, if you have nothing to put then just type N/A (not Applicable).

You will have a chance to add your resume to the end of your application you if you choose to; although a resume will not substitute for a complete application form.

Job Posting

Personal

Personal Information

First Name*:
Middle Name:
Last Name*:
Home Phone*:
Cell Phone:
Email Address*:

Addresses

Current Address

Street*:
City*:
State*:
Zip Code*:

Education

High School

School:
City:
State:
Diploma:

Undergrad School

School:
City:
State:
Diploma:
Deg/Cert/Dip:
Area of Study:

Grad School

School:
City:
State
Diploma:
Deg/Cert/Dip:
Area of Study:

Other School

School:
City:
State:
Diploma:
Deg/Cert/Dip:
Area of Study:

Employment

Employment Information

Position Applied For:
Date You Can Start:
Desired Salary :
Do You Prefer:
Can you work:
 Weekends
 Evenings
Available:
 M
 Tu
 W
 Th
 F
 Sa
 Su
Not Available:
Please answer all of the following questions.
1.
Are you at least 18 years of age and legally eligible to work for our company in the United States?
2.
Have you worked for this business before?
 
If yes, please provide dates and locations.
 
3.
Have you received a description of the job or been made aware of the essential functions of the job for which you are applying?
4.
Do you understand the job requirements?
 
If no, please explain.
 
5.
Are you on layoff and subject to recall?
6.
Have you ever been convicted by any court of a crime, other than a minor traffic violation; or been disbarred or excluded from participating in any Federal or State health care program? If yes, please explain. Note: Unless so stated on job application a conviction is not an automatic bar to employment.
 
If yes, please explain...
 
7.
Have you ever been discharged or asked to resign from a job?
 
If yes, please explain...
 

Employers

Employer

Employer:
City:
State:
Zip Code:
Phone:
Position Held:
From (m/yyyy):
To (m/yyyy):
Supervisor:
Duties:
Reason For Leaving:

Prior Employer (1)

Employer:
City:
State:
Zip Code:
Phone:
Position Held:
From (m/yyyy):
To (m/yyyy):
Supervisor:
Duties:
Reason For Leaving:

Prior Employer (2)

Employer:
City:
State:
Zip Code:
Phone:
Position Held:
From (m/yyyy):
To (m/yyyy):
Supervisor:
Duties:
Reason For Leaving:

Prior Employer (3)

Employer:
City:
State:
Zip Code:
Phone:
Position Held:
From (m/yyyy):
To (m/yyyy):
Supervisor:
Duties:
Reason For Leaving:

Skills

Job-related Skills

4.
Please list all states from which you hold or held a driver's license:
 

References

Reference (1)

Name:
Address:
Telephone:
Relationship:
Years Acquainted:

Reference (2)

Name:
Address:
Telephone:
Relationship:
Years Acquainted:

Resumes

Resume (Text Version)

Copy and Paste a text version of your resume here.

Upload File

Attach a file to your application submission

Agreement

Applicant's Certification Agreement

  1. I hereby certify that all statements and declarations made by me on this application are true, and I agree and understand that any misstatements, or omission of material facts will cause forfeiture on my part of all rights to employment with the Lompoc Valley Medical Center.
  2. Furthermore, if hired I may be required to submit verification on any information provided on this application.
  3. I understand that my employment is contingent upon successful completion of a medical examination and background investigation.
  4. The Lompoc Valley Medical Center is hereby authorized to make any investigation of my prior educational and work history, and contact supervisors and co-workers shown above.
  5. I understand that the Lompoc Valley Medical Center reserves the right to dismiss employees "at will".
  6. I understand that if I am bilingual, the Lompoc Valley Medical Center may require me to perform as an interpreter when necessary.
  7. I have read the job announcement for the position for which I am applying and believe I meet the qualifications of the position.
  8. If a current or former employee of the Lompoc Valley Medical Center, I authorize the department head or supervisor of the position for which I am applying to review my District personnel file.
 
Signature

Please provide your electronic signature. Type your name exactly as you did on your application.

Today's Date: 2010-07-29 12:51:58 PDT

THIS APPLICATION IS NOT AN EMPLOYMENT CONTRACT but merely is intended to evaluate suitability for employment. It is the policy of the company to provide equal employment to all qualified persons without discrimination on the basis of sex, race, color, religion, age, national origin, citizenship, disability, veteran status, or any other status protected under local, state or federal law. It is also the policy of the company to have the option of conducting pre-employment screening before a job offer is made. If a job offer is made, employment may be contingent upon the successful completion of a pre-employment drug screening and/or medical examination. This application will remain active for 3 years.

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