Lower Umpqua Hospital - Employment Application Form

This electronic application does not contain necessary consents for reference checks, verification of work experience and verification that all information provided is true and complete. This requires your signature and is a part of Lower Umpqua Hospital’s employment process. You may click HERE to download this authorization and mail it separately to Lower Umpqua Hospital or attach it to the actual application. Or, once an interview has been scheduled, you will be asked for such authorization in writing. If you are unwilling to give written authorization for background and reference checks, please exit this program now.

In addition, employment is made contingent upon the satisfactory completion of all of the following:

If you are unwilling to submit to these screenings, please exit the program now.

To Send your information by email, please fill out the Form below

Please use the TAB key to move from box to box
(hitting ENTER or RETURN will send the form).
You may use ENTER or RETURN to add a text line in the boxes where this is indicated.

Please type N/A in any boxes that do NOT apply to you, except in the case of duplicate entries
(i.e. References, past employment, colleges - if you only have one or two, please leave the remaining boxes blank).

Your First, Middle, and Last Name:

Your Email Address:

Your Social Security Number:

Your Present Address, City, State & Zip (You may use the ENTER key within this box.):

Your Present Phone Number:

Your Permanent Address, City, State & Zip (You may use the ENTER key within this box.):

Your Permanent Phone Number:

Position Applied For:

Salary Desired:

How Were You Referred to this Facility? (You may use the ENTER key within this box.):

Are You Applying For:

Are You Applying For Regular/Temporary:

Do You Have Relatives or Friends Employed In This Facility?:

In Which Department Do/Does He/She/They Work:

Date Available For Work:

Have You Ever Been Employed By This Facility? (When?):

Are You 18 Years Old Or Younger?:

Would You Consider Working Any Shift?:

Would You Consider Working Weekends & Holidays?:

Would You Consider Working Rotating Shifts?:

Would You Consider Working On Call?:

Shift Preference:

Are You a U.S. Citizen or an Alien Legally Authorized to Work in the United States?:

Have You Been Convicted of a Felony?:

A felony conviction does not automatically disqualify you from employment.

After Reviewing the Functions of the Job You Are Applying For,
Do You Have Any Physical/Mental Condition That Would Substantially
Limit Your Ability to Perform That Job? If Yes, Please Explain
(You may use the ENTER key within this box.):

Schools Attended - Grades Achieved:

High School / GED:

Name and Address of High School (You may use the ENTER key within this box.):

List Diploma or Degree:

College / Tech #1:

Name and Address of College/Technical School (You may use the ENTER key within this box.):

Course of Study:

List Diploma or Degree:

College / Tech #2:

Name and Address of College/Technical School (You may use the ENTER key within this box.):

Course of Study:

List Diploma or Degree:

College / Tech #3:

Name and Address of College/Technical School (You may use the ENTER key within this box.):

Course of Study:

List Diploma or Degree:

Area of Specialization or Major Interest
(You may use the ENTER key within this box.):

List Job Specific Skills and Equipment Experience
(You may use the ENTER key within this box.):

Professional Licenses and/or Certifications

Type:

State Issued:

Date:

Number:

Previous Experience

List Name, Address and Phone Number of Previous Employers with Most Recent Employer First

Job Title:

Employed From (Start Date):

Employed To (End Date):

Employer's Name:

Phone Number:

Address:

City/State/Zip:

Duties
(You may use the ENTER key within this box.):

Reason For Leaving:
(You may use the ENTER key within this box.):

Employment Check

May we contact your current employer?:

Comments regarding employment check:
(You may use the ENTER key within this box.):

Military Service & Volunteer Service

Did you serve in the U.S. Armed Services?:

What Branch?:

Have you volunteered your time or services?:

Explain:
(You may use the ENTER key within this box.):

Briefly describe duties and skills acquired through volunteer or military service:
(You may use the ENTER key within this box.):

References

Name:

Relationship:

Title:

Company Name:

Address:

City/State/Zip:

Telephone:

Resume

If you would like, you may include a resume by pasting it in this box, or sending it by email or fax THIS IS NOT REQUIRED:
(You may use the ENTER key within this box.):

You will be redirected back to a "Thank You Page" when your message is sent.

If you prefer to send it by email, please use this address: hr@luhonline.com

Please be aware that our email server will block email from some addresses. If you do not receive a reply from us in a reasonable amount of time, we most likely did not receive your message. Please follow-up to make sure we receive your resume.

You may also Fax your resume to 541-271-2941. Please include a cover sheet describing the job for which you are applying and stating that you have filled out our online application.