6640 Kaniksu Street Bonners Ferry, ID (208) www. BoundaryCommunityHospital.org. An Equal Opportunity Employer

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1 6640 Kaniksu Street Bonners Ferry, ID (208) www. BoundaryCommunityHospital.org An Equal Opportunity Employer Date: EMPLOYMENT APPLICATION PERSONAL DATA Name: First Middle Initial Last Current Mailing City State Zip Permanent Address (If other than above): Home Cell Message Number: POSITION(S) DESIRED JobTitle: 1 Full-Time First Choice Second Choice 1 Part-Time 1 Occasional 1 Temporary If temporary, indicate which months: Please tell us where you heard about the position you are applying for. BoundaryCommunityHospital.org Indeed.com Idaho Department of Labor (Job Service) Monster.com Bonner County Daily Bee Careerbuilder.com Bonners Ferry Herald Other Internet Job Board 1 Other Newspaper: Personal Referral Name 1 Other: AVAILABILITY Indicate shift(s) you are available to work 1 Days 1 Evenings 1 Nights Will you rotate shifts? Will you work weekends? Indicate the days you are available for work: 1 Monday 1 Tuesday 1 Wednesday 1 Thursday 1 Friday 1 Saturday 1 Sunday First date you are available for work: Do you have the legal right to be employed in the United States?: If offered a position, the Immigration Reform and Control Act of 1986 requires you to furnish proof of your employment authorization and your identity before you can begin work.

2 INFORMATION Do you have any relatives employed here? If yes, please indicate name(s), relationship and their position: Have you been previously employed here? If yes, give dates: Have you previously interviewed for employment here? If yes, for what positions(s) and when: Have you ever been convicted of a misdemeanor or felony? If yes, explain fully: Are you currently a tobacco user If yes, how often?: If applying for the position of Registered Nurse, Licensed Practical Nurse, Pharmacist, or Pharmacy Technician please answer the following question: In the past three (3) years, have you ever knowingly used any controlled substances, including narcotics, amphetamines, or barbiturates, other than those prescribed to you by a physician? 1Yes 1 No If yes, explain fully: ( A yes answer to these questions will not necessarily bar the applicant from employment) CHECK THE TRAINING AND/OR EXPERIENCE AREAS WHICH MAY QUALIFY YOU FOR THE POSITION(S) DESIRED BUSINESS/CLERICAL SERVICE AREAS PATIENT CARE SKILLS 1 Typing/Keyboard wpm: 1 Medical Terminology 1 Data Entry 1 Insurance Billing/Collections 1 Switchboard 1 Information Systems 1 Database Software 1 Spreadsheet Software 1 Customer Relations 1 Computer Software Proficiency 1 What Programs: 1 Floor Care Machines 1 Patient Tray Line 1 Cafeteria Serving 1 Quantity Cooking 1 Industrial Washers/Dryers 1 Autoclave 1 Electrical 1 Electronics 1 Mechanical 1 Plumbing 1 Refrigeration 1 Carpentry 1 Boilers 1 HVAC and Controls 1 Infection Control 1 Vital Signs 1 Bedside Testing 1 Home Health / Hospice 1 Isolation Procedures 1 IV Techniques 1 Emergency 1 Family Practice Clinic 1 ICU 1 Med/Surg 1 Surgery 1 Rehabilitation 1 Long-term Care What are your career goals?: PATIENT CARE APPLICANTS: What is your primary focus in Healthcare?:

3 WORK EXPERIENCE LIST MOST RECENT EMPLOYER FIRST AND PROVIDE ALL REQUESTED INFORMATION Job 1 Job 2 Job 3

4 WORK EXPERIENCE Continued Job 4 Job 5 Give your previous name: MILITARY EXPERIENCE LIST MILITARY INFORMATION Branch of Military: 1 N/A Dates Served (month/year): Job Duties and Responsibilities:

5 EDUCATION College School (Circle the highest year completed) Other: Indicate Each High School, Vocational School, School of Nursing, College or University attended. Name of School City State Course of Study Degree, Diploma, or Certificate Do you plan to resume your education? 1 Undecided If yes, when? Name and Location of School PROFESSIONAL REGISTRATION/LICENSURE Type of Registration or License State Number Date of Expiration If you do not have a required registration or license, have you applied for one? If an examination is required what date are you scheduled to take the examination? CERTIFICATION Type of Certificate State Date of Certificate PROFESSIONAL REFERENCES Name Professional Title Contact Number

6 APPLICANT S UNDERSTANDING Important: Read Before Signing I certify that the information on this application is complete and true. I understand that misrepresentation or omission of facts may result in immediate termination of any employment resulting from this application. I further understand that employment is contingent upon satisfactory completion of a criminal background check and requested pre-employment lab tests for controlled substances and that a positive test result will prohibit and/or cancel any offer of employment previously made by an authorized representative of Boundary Community Hospital. I understand and agree that I shall be subject to immediate termination if it shall be determined that my answers are untrue or that I have failed to disclose a material fact. I understand and agree that the fact that the employer has made or has not made an investigation or the fact that I have performed my work satisfactorily for any period of time to this determination, shall not constitute a waiver, abandonment, or bar of the right of the employer to take such disciplinary action. I understand that my employment shall be contingent with the Immigration Reform and Control Act of I further understand that my employment is contingent upon the verification of references furnished by me. I consent to and authorize the hospital and its personnel to request any information concerning my previous employment record as indicated on this application of employment including documentation on performance issues and or discharge notices. I hereby release all parties and persons connected with any request for information from all claims, liabilities, and damages for whatever reason arising out of furnishing such job related information. In conjunction with my application with Boundary Community Hospital, I understand that investigative background inquires are to be made on me which may include criminal convictions, motor vehicle and other reports. Employment at Boundary Community Hospital is at-will. That is, either you or Boundary Community Hospital may terminate the employment relationship at any time, with or without cause. The at-will relationship remains in full force and effect notwithstanding any statements to the contrary made by company personnel or set forth in any documents. This application does not constitute an employment contract. Signature of Applicant Note: Typing your name constitutes an Electronic Signature Date Almost finished...just a little more on the next page!

7 BACKGROUND Please complete and submit the attached Application Background Questionnaire with your application. Submission of this form is optional. Data collected will be used only in the aggregate, to assess the effectiveness of outreach efforts. Consideration for this job will not be affected by failure to submit the form. Boundary Community Hospital is requesting your completion of this form to assist the Hospital in evaluating and improving its efforts to publicize job openings and to encourage applicants for employment from a diverse group of qualified candidates, including minorities and persons with disabilities. The hospital will use the data you supply to determine how many applicants are from different groups and how many of these applicants are qualified for the job in question. The hospital will then assess the effectiveness of specific outreach efforts and the means of communicating information on job vacancies in light of this information. EFFECTS OF NONDISCLOSURE: Providing the information requested on this form is voluntary. This information will have no effect on hiring decisions. Information provided on this form will be used for program evaluation. Personal identifying information will not be included in the tabulation of data in the DOL database. Solicitation of this information is in accordance with 5 CFR Section 720, "Federal Equal Opportunity Recruitment Program" (FEORP). Please complete the following: Name: Sex: 1 Female 1 Male Do you have a disablity? If you checked yes above, is your disabilitiy one of the targeted disabilities listed below? Blind Deaf Missing Extremity(s) Partial Paralysis Complete Paralysis Convulsive Disorder Mental Retardation Mental Illness Genetic or Physical Condition Affecting Limbs or Spine Title of Position for which applying: Ethnic Self-Identification Are you Hispanic, Latino, or of Spanish Origin? (Definition: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.) Please read the descriptions, and then mark one or more races to indicate what you consider yourself to be. 1 American Indian or Alaskan Native: A person having origins in any of the original peoples in North and South America, including Central America, and who maintains tribal affiliation or community attachment. 1 Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian sub-continent including, but not limited to, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. 1 Native Hawaiian or other Pacific Islander islands: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islander islands. 1 Black or African American: A person having origins in any of the black racial groups of Africa. 1 White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. The submit button will take you to your application where the Employment Application will be ready to send. Remember to attach your cover letter and resume (if you have one) before sending your . If you prefer not to use the submit button, save your completed Employment Application to your computer and attach it to an addressed to employment@bcch.org. Again, remember to attach your cover letter and resume (if you have one) before sending the .