Thank you for your interest in employment with Black Hills Surgical Hospital and Black Hills Urgent Care. Please note: Our application needs to be filled out in ADOBE ACROBAT and using Internet Explorer. If you are using anything other than Adobe Acrobat and Internet Explorer, please save the completed application to your desktop, then attach it to an email. We will acknowledge all applications received via email. If you do not receive an acknowledgement within 1 business day of submission, please contact us. If you have any questions, please contact HumanResources@bhsh.com
Mailing Address 1868 Lombardy Drive Rapid City, SD 57703 Fax: 605-721-4949 Email: humanresources@bhsh.com Websites: www.bhsh.com www.bhucare.com APPLICATION FOR EMPLOYMENT An Equal Opportunity and Affirmative Action Employer As an equal opportunity and affirmative action employer, we do not discriminate against any employee or applicant for employment on the basis of race, color, sex, national origin, religion, age, genetic information, disability, veteran status or any other classification protected by federal, state, or local law, except where a bona fide occupational qualification exists. We do not discriminate against any qualified applicant with a disability as defined under the Americans with Disabilities Act and will make reasonable accommodations, when they do not impose an undue hardship on us. If you require reasonable accommodation to complete this application and/or any other aspect of the employment application process, please contact the Human Resources Department at 605-721-4922 or 605-721-4923. PLEASE PRINT Date of Application: / / Position Applied For: Referral Source: Advertisement Friend Employee BHSH/BHUC Website Dept of Labor Other Name of Source (if applicable): Name: Last First Middle Address: City State Zip Code Home : Cell Phone: Email Address: Have you ever been employed here before? Yes No If yes, give date: Are you employed now? Yes No May we contact your present employer? Yes No May we contact you at work? Yes No If yes, work number and best time to call:( ) Time AM/PM On what date would you be available for work? (When requesting to meet or exceed your current rate of pay, please attach a copy of your pay advice to validate your request.) Expected Salary: Are you available to work: Full-Time Part-Time PRN (as needed) Temporary Are you available to work: Days Mornings Afternoons Evenings Nights Weekends Holidays Will you work overtime if required? Yes No Will you travel if required? Yes No Is anyone related to you employed by BHSH/BHUC? Yes No If yes, please give their name and relationship to you: Do you smoke or otherwise use tobacco products? Yes No Have you ever been convicted of a felony? Yes No A conviction will not necessarily disqualify an applicant from employment. If yes, please explain: Have you been convicted of a criminal offense related to health care or have you been debarred, excluded, or otherwise determined ineligible for participation in governmental health care programs? Yes No If yes, please explain: If hired, you will be required to submit documents sufficient to establish employment authorization and identity in compliance with the Immigration Reform and Control Act of 1986. While you need not provide this proof of citizenship or immigration status at the time you are interviewed, please be prepared to assure us that you can do so immediately upon being hired. We participate in the E-Verify Program.
EDUCATION: School: Name/Address Course of Study Choose Last Did You Diploma/ Year Completed Graduate? Degree High School or GED 1 2 3 4 College 1 2 3 4 College 1 2 3 4 Technical, Business or Professional 1 2 3 4 LIST ALL PROFESSIONAL LICENSES/CERTIFICATIONS EVER HELD (start with the most current): Type State Expiration Date Registration No. Has your professional license ever been suspended, conditioned or revoked in any state? No Yes If yes, please explain: List professional, trade, business or civic activities and offices held. (You may exclude those which indicate race, color, religion, sex, age, national origin, disability.) EMPLOYMENT Start with your present or last job. Include military service assignments and volunteer activities. Exclude organization names which indicate, for example, race, color, religion, sex, age, disability, or national origin. Employer Name Employer Name 2
Employer Name Employer Name Employer Name PROFESSIONAL REFERENCES: List names and telephone numbers of three professional references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you. Name & Address Number Years Known State any additional information you feel may be helpful to us in considering your application: 3
APPLICANT S STATEMENT I understand and agree that any misrepresentation by me in this application will be sufficient cause for rejection of this application and/or termination of employment if I am hereafter employed by Black Hills Surgical Hospital, LLP (BHSH)/Black Hills Urgent Care, LLC (BHUC). In consideration of my employment, I agree to conform to the policies and procedures of BHSH/BHUC. Furthermore, if I am hired, I understand that I am free to resign at any time for any reason, and that BHSH/BHUC reserves the right to terminate my employment at any time for any reason, with or without cause, and without prior notice. I understand that no representative of BHSH/BHUC has authority to make any representations or assurances to the contrary. It is BHSH/BHUC policy to provide a safe and healthy work environment. I understand that I will be requested to submit to a urine-based cotinine test to detect the presence of all forms of nicotine. I understand that if an offer of employment is made and I, the applicant, test positive for nicotine, the offer of employment may be withdrawn. I further understand that I have the right to refuse to submit to such tests of my own free will, but that such refusal may be considered a withdrawal of my application for employment. I understand that if BHSH/BHUC makes an offer of employment to me it will be a conditional offer of employment and I will be requested to submit to a physical examination and to provide information in response to medical inquiries, the results of which might disqualify me from employment. If requested, I agree to furnish such information and to submit to such physical examination. I further understand that I have the right to refuse to submit to such examination of my own free will, but that such refusal may be considered a withdrawal of my application for employment. In accordance with the Drug-Free Workplace Act of 1988, BHSH/BHUC has established a Drug-Free Workplace company-wide policy. It is BHSH/BHUC policy to maintain a work environment that is safe for all employees and conducive to attaining high work standards. Therefore, if an offer of employment is made, hiring is contingent upon me, the applicant, passing a urine drug test. I understand that I will be requested to submit to a test to detect the current illegal use of drugs and, if the test results identify that I am a current illegal user of drugs, I will not be eligible for employment by BHSH/BHUC. I further understand that I have the right to refuse to submit to such tests of my own free will, but that such refusal may be considered a withdrawal of my application for employment. I understand that BHSH/BHUC may obtain a Consumer Report / Investigative Consumer Report for the purpose of evaluating me for employment, promotion, reassignment, or retention. I understand that I am entitled to obtain, by written request, disclosure of the nature and scope of the report. BHSH/BHUC is an equal opportunity and affirmative action employer and BHSH/BHUC does not discriminate in employment. No question on this application is used for the purpose of limiting or excluding BHSH/BHUC consideration of me for employment on a basis prohibited by federal, state or local law, nor is it used by BHSH/BHUC for the purpose of attempting to obtain information prohibited by federal, state or local law. I understand that BHSH/BHUC will consider this application to contain current information for a period of only sixty (60) days. I understand it will be necessary for me to complete a new application for future open, advertised positions. Black Hills Urgent Care, LLC, is a wholly owned subsidiary of Black Hills Surgical Hospital, LLP, which is proudly owned by physicians. BY SIGNING BELOW I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE APPLICANT S STATEMENT. Signature Date 4 Revised 03-01-14
Applicant Invitation to Self-Identify This information is requested on a voluntary basis. In order to help us comply with Federal Equal Opportunity record keeping and legal requirements, we encourage you to answer the questions below. Please note that Black Hills Surgical Hospital/Black Hills Urgent Care adheres to and believes in equal employment opportunity for all applicants and employees without regard to race, color, religion, national origin, gender, age, disability, veteran status, genetics, gender identity or expression, or any other status protected by law. This pre-employment information will be kept in a confidential database separate from employment applications/resumes. Refusal to provide this information will not disqualify your application. Part A Name: Date: Position Applied for: How did you learn about this position? Part B 1. What is your gender? 2. Are you Hispanic or Latino? 3. What is your race? (Check one) Male Female Yes. Hispanic/Latino means a person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race. If you check this box, skip questions 3. No. Continue to the next question. White: A person having origins in any of the original peoples of Europe, the Middle East or North Africa. Black or African American: A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander: A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands. Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam. American Indian or Alaskan Native: A person having origins in any of the original peoples of North and South America (including Central America) and who maintains cultural identification through tribal affiliation or community recognition. Two or More Races: All persons who identify with more than one of the above five races. I refuse to provide information about my race and gender (Check this box only if you did not complete part B. You must fill in part A). Are you a Protected Veteran? (See definitions attached). Yes No Please sign here Signature:
Protected Veteran Descriptions Disabled Veteran. A veteran who is entitled to compensation (or would be if the person were not receiving military retired pay) for a service-connected disability under laws administered by the U.S. Department of Veterans Affairs or a person who was discharged or released from active duty because of a service-connected disability. Other Protected Veteran of War, Campaign or Expedition. Veteran who served on active duty in the U.S. Armed Forces during a war or in a campaign or expedition for which a campaign badge has been authorized. A list of these wars, campaigns and expeditions can be found at http://www.opm.gov/veterans/html/vgmedal2.asp. Armed Forces Service Medal Veteran /Noncombat Veteran who Earned Armed Forces Service Medal. Veteran who, while serving on active duty in the Armed Forces, participated in a United States military operation for which an Armed Forces Service Medal was awarded pursuant to Executive Order 12985. This service medal is a noncombat medal that covers significant U.S. military operations that don t encounter foreign armed opposition or imminent hostile action. An explanation and list of operations that qualify for the Armed Forces Service Medal can be found at http://foxfall.com/csm-common-afsm.htm. Recently Separated Veteran: Any veteran during the three-year period beginning on the date of the veteran s discharge or release from active duty in the U.S. military, ground, naval or air service.