Gila River Health Care Corporation
Gila River Health Care Corporation
EMPLOYMENT APPLICATION

You can download an application, print it out, and fill it out by hand:
Download an application in PDF format
(Requires free Adobe Acrobat software – download it now)
 Download an application in Microsoft Word format

Or, fill your application out on-line and hit the submit button below when completed.

 
GENERAL INFORMATION
Name (Last/First/Ml): Social Security Number (optional)
Home or Mailing Address: City: State: Zip:
Phone: H/ W/ Message:

Can you submit your legal right to work in the U.S.? Yes No
Do you meet the age requirement for employment? Yes No
Are you a U.S. citizen or authorized to work in the United States? Yes No
Preference is given to qualified GRIC Tribal Members and other Indian Tribal members.
Are you an enrolled member of the GRIC? Yes No          Enrollment Number
Are you a member of a Federally recognized Indian Tribe? Yes No         Tribal Affiliation
POSITION
Position applying for: (Title) Announcement Number
When can you start to work? What is the lowest pay you will accept?
Are you willing to work? Full Time        Part Time (# of hours )        Weekends        Shifts        Rotating shifts
May we contact your current employer? Yes No         A “No” will not affect our review of your qualifications
Have you had a name change that may hinder verification of your work record? Yes No
If “YES” names(s) used
EDUCATION INFORMATION: You will also need to provide a copy of your high school diploma, GED, all College transcripts and licensure as supplementary documentation.
Institutions

Name and Address
No. of Years Attended
Did You Graduate?
Degree/Diploma Earned
High School
Yes      No
Yes      No
GED Yes      No
College or University
Yes      No
Yes      No
Graduate Education
Yes      No
Yes      No
Other special education or training
   
EMPLOYMENT HISTORY INFORMATION
List below all present and past employment beginning with your most recent. Account for the last 10 years including periods of unemployment and military service. All sections must be completed even if resume is attached.
Name and Address of Company or Institution

From: Month & Year   

To: Month & Year       

Average Number
of Hours Worked
Reason for Leaving:

Position or title

 Supervisor
 Telephone and Area Code

Starting Salary:

Ending Salary:

Brief Description of duties, including title and number of staff supervised
Name and Address of Company or Institution

From: Month & Year   

To: Month & Year       

Average Number
of Hours Worked
Reason for Leaving:

Position or title

 Supervisor
 Telephone and Area Code

Starting Salary:

Ending Salary:

Brief Description of duties, including title and number of staff supervised
Name and Address of Company or Institution

From: Month & Year   

To: Month & Year       

Average Number
of Hours Worked
Reason for Leaving:

Position or title

 Supervisor
 Telephone and Area Code

Starting Salary:

Ending Salary:

Brief Description of duties, including title and number of staff supervised
Name and Address of Company or Institution

From: Month & Year   

To: Month & Year       

Average Number
of Hours Worked
Reason for Leaving:

Position or title

 Supervisor
 Telephone and Area Code

Starting Salary:

Ending Salary:

Brief Description of duties, including title and number of staff supervised
Name and Address of Company or Institution

From: Month & Year   

To: Month & Year       

Average Number
of Hours Worked
Reason for Leaving:

Position or title

 Supervisor
 Telephone and Area Code

Starting Salary:

Ending Salary:

Brief Description of duties, including title and number of staff supervised
Name and Address of Company or Institution

From: Month & Year   

To: Month & Year       

Average Number
of Hours Worked
Reason for Leaving:

Position or title

 Supervisor
 Telephone and Area Code

Starting Salary:

Ending Salary:

Brief Description of duties, including title and number of staff supervised
REFERENCES:
List three persons not related to you and not listed as a supervisor in your experience listings. These persons should be able to answer questions about your qualifications and fitness for this position.
FULL NAME OF REFERENCE
TELEPHONE NUMBER(S)
ADDRESS

ADDITIONAL INFORMATION:

Have you ever been convicted of a felony? Yes No
Have you ever been arrested for or charged with a crime involving a child? Yes No
(If “YES”, provide the date, explanation of the violation, disposition of the arrest or charge, place of occurrence, and the name and address of the police department or court involved)

Have you ever been found guilty of, or entered a plea of no contest, or guilty to, any offense under Federal, State, or Tribal law involving crimes of violence, sexual assault, molestation, exploitation, contact or prostitution, or crimes against persons? Yes No
(If “YES” to above questions, provide the date, explanation of the violation, disposition of the arrest or charge, place of occurrence, and the name and address of the police department or court involved). Attach required information on a separate sheet.

During the last 10 years were you fired from any job for any reason, did you quit after being told you would be terminated or did you leave by mutual agreement because of specific problems. Yes No

Do you have a relative(s) working at Gila River Health Care Corporation? Yes No
If YES, state the identity and relationship

READ THE FOLLOWING CAREFULLY BEFORE YOU SIGN:

In consideration of my employment I agree to conform to policies and procedures of the GRHC Corporation, and further agree that my employment and compensation are “at will” of the Corporation and can be terminated, with or without cause, and with or without notice, at any time at the option of either The Corporation or myself. I understand and agree that these terms can only be modified by the Chief Executive Officer of the Corporation in writing, provided that such writing specifically acknowledges that it is a modification of this agreement and is signed by the Chief Executive Officer. No supervisor, representative, agent or employee of the Corporation has now, or has had in the past any authority to enter into any agreement for employment for a specified period of time, or to make any agreement which is contrary to or a modification of the above items, nor can any policies of the Corporation, either written or oral, modify the above terms.

l certify that all information supplied in this application, and my attached resume, is true and correct. I understand that because the Gila River Health Care Corporation will rely on this application in making its employment decision, any false or misleading information furnished by me regarding this application will result in the rejection of this application or termination if employed by the Corporation.

I hereby authorize all education institutions which I have attended, all branches of the U.S. Military service in which I have served, all of my former employers, any court systems, to furnish to the GRHCC, or its representatives, any and all information concerning my education, military services, former and current employment, and/or criminal convictions. In addition, I hereby agree to hold harmless and release all of said institutions, services, employers, courts and representatives from any and all claims that I may have, or which may arise, against any and/or all of them, including GRHCC as a result of their furnishing information to the Gila River Health Care Corporation.


Acknowledgement (type name in box)        Date

        

Return to Employment Opportunities Page
Return to Home Page
Gila River Health Care Corporation address and phone