1. art and entertainment
2. visual art and design
3. painting

Orem Employment Application
473 West 1400 North
Orem, UT 84057
Ph: 801.919-8590 | Fax: 801.765.4897
Please print legibly. Send or fax your completed application to the above address. Incomplete applications will not be
considered in the employment process.
Job Position
What position are you applying for:________________________________________________________________________________________
Applicant Contact Information
Last Name:________________________________________ First Name:____________________________________ Middle Initial:_________
Street Address:____________________________________________ City:___________________________State:______ Zip:___________
Email:_____________________________________________________ Phone:_____________________________________________________
Employment Desired
Are you applying for:

Yes

No
Regular full-time (at least 32 hours per week)

Yes

No
Regular part-time (less than 32 hours per week)

Yes

No
PRN work (on call, per diem)
Are you available to work:

Yes

NoWeekends

Yes

No
Rotating shifts
If you are hired, on what date can you start work:_____________________________________________________________________________

Yes

No
Have you read a job description for the position, which describes functions of the job?
Personal Information

Yes

No
Have you ever applied to or worked for Rocky Mountain Care?
If yes, when?___________________________________________________________________________________________

Yes

No
Do you have any friends/relatives working for Rocky Mountain Care?
If yes, include their name(s) and relationship to you:___________________________________________________________
_____________________________________________________________________________________________________
What prompted you to apply to Rocky Mountain Care for work:_________________________________________________________________
_____________________________________________________________________________________________________________________

Yes

No
If hired, would you have reliable means or transportation to and from work?

Yes

No
Are you at least 18 years old? If under 18, employment is subject to verification that you are minimum legal age)

Yes

No
If hired, can you present evidence of your U.S. citizenship, or proof of your legal right to live and work in this county?

Yes 
No
Are you able to perform the essential functions of the job for which you are applying, either with or without
reasonable accommodation?
Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to
perform essential functions. Employment may be subject to passing a medical examination, and skill and agility tests.
If no, describe the functions that cannot be performed:________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Personal Information (continued)

Yes

No
Page 2
Have you ever been convicted of a criminal offense (felony or misdemeanor)?
If yes, state nature of the crime(s), when and where convicted and disposition of the case:____________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
No applicant will be denied employment solely on the grounds of conviction offense. The nature of the offense, the surrounding circumstances
and the relevance of the offense to the position(s) applied for may, however, be considered.
Education, Training and Experience
High School Information
Name of High School:____________________________________________________
Street Address:____________________________________________ City:___________________________State:______ Zip:___________
# Years Completed:_______
Did you graduate? Yes
 No
Degree/Diploma Received:_______________________________
College/University Information
Name of College/University:_______________________________________________
Street Address:____________________________________________ City:___________________________State:______ Zip:___________
# Years Completed:_______
Did you graduate? Yes
 No
Degree/Diploma Received:_______________________________
Vocational/Business Information
Name of Vocational/Business School:________________________________________
Street Address:____________________________________________ City:___________________________State:______ Zip:___________
# Years Completed:_______
Did you graduate? Yes
 No
Degree/Diploma Received:_______________________________
Health Care Information
Name of Health Care School:_______________________________________________
Street Address:____________________________________________ City:___________________________State:______ Zip:___________
# Years Completed:_______
Did you graduate? Yes
 No
Degree/Diploma Received:_______________________________
Professional Licenses and/or Certificates
Type:_____________________________________________________ Organization or State Issued:___________________________________
Date Issued:_______________________________________________ Number:____________________________________________________
Type:_____________________________________________________ Organization or State Issued:___________________________________
Date Issued:_______________________________________________ Number:____________________________________________________
Type:_____________________________________________________ Organization or State Issued:___________________________________
Date Issued:_______________________________________________ Number:____________________________________________________

Yes

No
Was your license/certificate ever revoked or suspended?
If yes, state reason(s):____________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Date of revocation or suspension, and date of reinstatement:___________________________________________________
_____________________________________________________________________________________________________
Employment History
Page 3
List below all present and past employment starting with your most recent employer (last five years is sufficient).
Account for all periods of unemployment.
Name of Employer:_______________________________________________________
Street Address:____________________________________________ City:___________________________State:______ Zip:___________
Phone:____________________________________________________ Supervisor’s Name:___________________________________________
Your position(s) and duties:_______________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Dates of Employment:From:______________________________To: ________________________________
Pay:Starting:____________________________Ending: ____________________________
Pay Rate (check one):
Hourly
Weekly
Yearly
Reason for leaving:______________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________

Yes

No
If currently employed, may we contact your employer?
Name of Employer:______________________________________________________________________________________________________
Street Address:____________________________________________ City:___________________________State:______ Zip:___________
Phone:____________________________________________________ Supervisor’s Name:___________________________________________
Your position(s) and duties:_______________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Dates of Employment:From:______________________________To: ________________________________
Pay:Starting:____________________________Ending: ____________________________
Pay Rate (check one):
Hourly
Weekly
Yearly
Reason for leaving:______________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________

Yes

No
May we contact this employer for a reference?
Name of Employer:______________________________________________________________________________________________________
Street Address:____________________________________________ City:___________________________State:______ Zip:___________
Phone:____________________________________________________ Supervisor’s Name:___________________________________________
Your position(s) and duties:_______________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Dates of Employment:From:______________________________To: ________________________________
Pay:Starting:____________________________Ending: ____________________________
Pay Rate (check one):
Hourly
Weekly
Yearly
Reason for leaving:______________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________

Yes

No
May we contact this employer for a reference?
References
Page 4
List below three persons not related to you who have first hand knowledge of your work performance within the last
three years.
First Name:________________________________________________ Last Name:__________________________________________________
Number of Years Acquainted:______________________________________________
Street Address:____________________________________________ City:___________________________State:______ Zip:___________
Email:_____________________________________________________ Phone:_____________________________________________________
First Name:________________________________________________ Last Name:__________________________________________________
Number of Years Acquainted:______________________________________________
Street Address:____________________________________________ City:___________________________State:______ Zip:___________
Email:_____________________________________________________ Phone:_____________________________________________________
First Name:________________________________________________ Last Name:__________________________________________________
Number of Years Acquainted:______________________________________________
Street Address:____________________________________________ City:___________________________State:______ Zip:___________
Email:_____________________________________________________ Phone:_____________________________________________________
Employment Application Certification
Please read carefully each paragraph below. Each item below must be checked for your application to be considered.
 I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment
and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned
applicant, have personally completed this application. I understand that any omission or misstatement of material fact on
this application or on any document used to secure employment shall be grounds for rejection of this application or for
immediate discharge if I am employed, regardless of the time elapsed before discovery.
 I hereby certify that I have never been excluded from participation in Medicare and State Healthcare programs, as defined
by sections 1128 and 1156 of the Social Security Act.
 I hereby authorize the company to thoroughly investigate my references, work record, education and other matters related
to my suitability for employment and, further authorize the references I have listed to disclose to the company any and
all letters, reports and other information related to my work records, without giving me prior notice of such disclosure.
In addition, I hereby release the company, my former employers and all other persons, corporations, partnerships and
associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or
disclosure.
 I understand that nothing contained in the application, or conveyed during any interview which may be granted or during
my employment, if hired, is intended to create an employment contract between me and the company. In addition,
I understand and agree that if I am employed, my employment is for no definite or determinable period and may be
terminated at any time, with or without prior notice, at the option of either myself or the company, and that no promises or
representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the
company’s designated representative.
Signature and Date
Signature:_______________________________________________________________________Date:_________________________________
Pursuant to Title VII of the Civil Rights Act of 1964, Section 504 of the Rehabiitation Act of 1873, and the Age Discrimination Act of 1967, Rocky
Mountain Care is an Equal Opportunity Employer and does not make any distinction based on race, color, sec, religion, national origin, disability
or age in any condition of employment. Rocky Mountain Care advocates a drug free workplace and supports this goal with an Employee Drug and
Alcohol Testing Program.