We are an equal opportunity employer and do not unlawfully discriminate in employment. No question on this application is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state or federal law. Equal access to employment, services, and programs is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the organization.

 

Please fill out and submit the form below.

*** Please email your resume to recruiter@pimalung.com. Once your resume has been received, you will be sent a PLS survey via email to complete as part of the application process. Make sure to include your email address with your resume. Please complete the PLS survey and email it back as soon as possible in order to complete your application. ***

Please use an HTML5 compliant browser, such as Google Chrome, Firefox, or Opera to fill out this application. Windows users can also use Edge (formerly Internet Explorer). Mac users can also use Safari.

Applicant Information

Applicant Name:* 

 

Date:* 

 

Position(s) applying for:*

 

  

 

Email Address:* 

 

Primary Phone:* 

 

Secondary Phone: 

 

Street Address:* 

 

City:* 

 

State:* 

 

Zip Code:* 

Type of Employment

Start Date:* 

 

Employment type*: 

 

Referred by: 

Employment Specifics

Spanish Bilingual?*

no yes

 

Fluent in other languages:

 

What is your means of transportation to work:

 

Can you meet the attendance requirements?*

no yes

 

If you are hired. Will you be able to work Overtime?*

no yes

 

Hobbies & Interests:

 

Can you travel if required?*

no yes

 

Can you submit proof of legal employment authorization and identity?*

no yes

 

Have you ever been previously employed by Pima Lung & Sleep?*

no yes

 

If you are under 18, can you submit a work permit if required?*

no yes NA

 

Have you ever been convicted of a CRIME or Felony ? If yes, please explain.*
(A conviction will not automatically bar employment):

 

no yes: 

Number of convictions: 

 

Nature of the offense(s) & or conviction:
  

 

Dates of conviction (MM/YYYY): 
 to 

 

 

What “sentence" was imposed: 

 

Types of rehabilitation received: 

Summary of Skills & Qualifications

What information would you like to bring to the employer’s attention?

 

  

 

Why do you believe that you are qualified for the position?

 

  

 

What EHR/EMR’s do you have experience with?

 

  

 

What types of software do you have experience using ?

 

  

References

Check the applicable boxes to show forms.

 

REFERENCE #1 

Name:* 

 

Phone:* 

 

Relation to Applicant:* 

 

Duration of Relationship:* 

 

What would this reference tell us about you?* 

 

REFERENCE #2 

Name:* 

 

Phone:* 

 

Relation to Applicant:* 

 

Duration of Relationship:* 

 

What would this reference tell us about you?* 

 

REFERENCE #3 

Name:* 

 

Phone:* 

 

Relation to Applicant:* 

 

Duration of Relationship:* 

 

What would this reference tell us about you?* 

 

Education

Check the applicable boxes to show forms.

 

High School 

School Name: 

 

Years attended: 

 

Favorite subjects: 

 

Degree: 

 

GPA: 

University/College 

School Name: 

 

Years attended: 

 

Major: 

 

Degree: 

 

GPA: 

Graduate School 

School Name: 

 

Years attended: 

 

Major: 

 

Degree: 

 

GPA: 

Trade/Technical/Vocational School 

School Name: 

 

Years attended: 

 

Major: 

 

Degree: 

 

GPA: 

Additional 

School Name: 

 

Years attended: 

 

Major: 

 

Degree: 

 

GPA: 

Military Service 

Type: 

 

Dates of service(mm/yyyy):  to 

 

Rank: 

 

Training: 

Health Career Pathway
Allied Health Schools 

School Name: 

 

Years Attended(yyyy):  to 

 

Degree: 

 

GPA: 

Respiratory Therapy School 

School Name: 

 

Years Attended(yyyy):  to 

 

Degree: 

 

GPA: 

Diagnostic Medical Sonography School 

School Name: 

 

Years Attended(yyyy):  to 

 

Degree: 

 

GPA: 

 

Year(s) degree was issued: 

Employment History

Please provide all employment information for your past five employers starting with the most recent. (Check the applicable boxes to show forms.)

 

EMPLOYER #1 

Employer: 

 

Job Title: 

 

per hour per year Salary: 

 

Start Date: 

 

End Date: 

 

Telephone #: 

 

 

Supervisor: 

 

Street Address: 

 

City: 

 

State: 

 

Zip Code: 

 

Summary of Job Duties: 

 

Reason for leaving (please be specific): 

EMPLOYER #2 

Employer: 

 

Job Title: 

 

per hour per year Salary: 

 

Start Date: 

 

End Date: 

 

Telephone #: 

 

 

Supervisor: 

 

Street Address: 

 

City: 

 

State: 

 

Zip Code: 

 

Summary of Job Duties: 

 

Reason for leaving (please be specific): 

EMPLOYER #3 

Employer: 

 

Job Title: 

 

per hour per year Salary: 

 

Start Date: 

 

End Date: 

 

Telephone #: 

 

 

Supervisor: 

 

Street Address: 

 

City: 

 

State: 

 

Zip Code: 

 

Summary of Job Duties: 

 

Reason for leaving (please be specific): 

EMPLOYER #4 

Employer: 

 

Job Title: 

 

per hour per year Salary: 

 

Start Date: 

 

End Date: 

 

Telephone #: 

 

 

Supervisor: 

 

Street Address: 

 

City: 

 

State: 

 

Zip Code: 

 

Summary of Job Duties: 

 

Reason for leaving (please be specific): 

EMPLOYER #5 

Employer: 

 

Job Title: 

 

per hour per year Salary: 

 

Start Date: 

 

End Date: 

 

Telephone #: 

 

 

Supervisor: 

 

Street Address: 

 

City: 

 

State: 

 

Zip Code: 

 

Summary of Job Duties: 

 

Reason for leaving (please be specific): 

Applicant Signature

I hereby authorize Pima Lung & Sleep to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability Pima Lung & Sleep and it's representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information.

 

I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered.

 

If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or Pima Lung & Sleep can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.

 

I understand that it is the policy of Pima Lung & Sleep not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that person's need for a reasonable accommodation as required by the ADA.

 

I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in the immediate termination of employment.

 

I represent and warrant that I have read fully and understand the foregoing, and that I seek employment under these conditions.

 

 

Applicant Signature (please type your full name in the box):

 

Signature:* 

 

Date:* 

 


 

*required information