Online Employment Application

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resource Department.

If you experience any issues with our online application, please contact us at or at 308-697-1136. Thank you!

Applicant Data

Address History

Provide your physical address for the last seven years. Begin with your present or current address.
Current Address:


Former Address (1):


Former Address (2):



Answering 'yes' to these questions does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.
Employment History

Provide the following information for your last seven (7) years of employment. Start with your present or most recent job. Include any assignments or volunteer activities, self-employment, summer and part-time jobs.
Dates Employed:



Dates Employed:



Dates Employed:



References (Do Not Include Family Members)

Educational Background
High School:



Special/Related Training

(For example: Clinical Experience, Home Health Care, Urgent Care, Senior Care, Pharmacy, Voluntary Services, etc.)
License and Certification Information
List all applicable licenses or certifications that you have and their expiration dates below.

Applicant Statement

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from the employer's service, whenever it is discovered.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other person, corporations or organizations for furnishing such information about me.

In connection with my application for employment, I authorize any insurance company, employer, educational institution, law enforcement organization, state and federal government agency, information service bureau, medical facility, and other persons contacted to release information regarding my character, performance, qualifications, background and reason for termination of past employment to Tri Valley Health System or its agent and release all parties involved in providing said information from any responsibility or liability.

I also authorize the release of my driving history, criminal records, worker compensation records and investigative consumer report and understand that it may contain information about my background, mode of living, character, and personal reputation.

I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law.

I understand that this application remains on file for six months. However, if I have not heard from the employer within 90 days and still wish to be considered for employment, it may be necessary to fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied, oral, or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in the regard.
Further, I understand that, if I receive a conditional job offer, and prior to beginning employment, I may be requested to undergo a pre-employment medical examination, including providing body substance samples. In the event that I have a disability that will affect my ability to take the test, I will so inform the employer prior to the administration of the test so that reasonable accommodation can be made. The employer reserves the right to require medical documentation regarding the need for accommodation.



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