Pikes Peak Regional Hospital
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Application ID:
*Position(s) applying for
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Status sought: Full Time Part Time PRN/on call
*
Name :
Other Name(s) You Have Used :
*Present Address :
*Main Telephone :
Alternate Telephone :
*Email :
Salary Expected: $per
*
Date available for work (mm/dd/yyyy) :
Are you willing to work (check all that apply) : Days Evenings Nights Weekends
How did you become aware of the position for which you are applying? :
*Are you 18 years of age or older? : Yes No
Have you previously worked or volunteered at Pikes Peak Regional Hospital? : Yes No
If yes, provide the dates, and job title :
Are you legally eligible to be employed in the United States? : Yes No
(Proof of identity and eligibility will be required upon employment.)
Have you ever been convicted of a crime other than a minor traffic offense? : Yes No
(A conviction will not necessarily automatically disqualify you for employment.)
If yes, explain :
Professional and technical licenses :
Has your professional license/certification ever been suspended, placed on
probationary status or revoked? : Yes No
If yes, explain :
Membership in professional organizations :
Have you ever been excluded from participation as a provider in the Medicare program? : Yes No
If yes, provide dates of exclusion and reinstatement :
Were you ever included on the General Services Administration's list of debarred contractors? : Yes No
Were you ever included on the Office of Inspector General's list of excluded individuals/entities? : Yes No
If yes, explain :

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