PROVIDENCE MEDICAL GROUP
Application for Employment

This company is an equal opportunity employer

NOTE: Please fill in all fields; if a field does not apply, please type "none"

PERSONAL INFORMATION

Name (Full - Last, First MI): SSN: Date:

Address: Home Phone:

E-Mail Address: Are you 18 years of age or older? Yes No

Type of position applying for (describe)?

Full-time Part-time Temporary

Salary or rate of pay desired? Date available to start work?

Will you work overtime hours? Yes No

Do you have a reliable means of transportation? Yes No

Please list below three persons you have known for at least one year (exclude former and employers and relatives).

Name & Occupation Address Phone No.

Name & Occupation Address Phone No.

Name & Occupation Address Phone No.

Have you ever been employed by Providence Medical Group, Inc. or Providence Health Partners ("PMG" or "PHP)? Yes No

If yes, please list dates of employment, location and position held:

Do you currently have any relative(s) working within the PMG/PHP? Yes No

If yes, please list employee name(s) and PMG/PHP location(s)

Name/Relationship Location

Do you have a legal right to be employed in the U.S. Yes No (If yes, proof will be required)

PREVIOUS EMPLOYERS

Company Name: Phone:

Address: Supervisor Name:

Employed From:   to   Position: Duties:

Reason for Leaving: Starting Wage: Last Wage:

Company Name: Phone:

Address: Supervisor Name:

Employed From:   to   Position: Duties:

Reason for Leaving: Starting Wage: Last Wage:

EDUCATION

High School: Name & Location:

Did you graduate? Yes No    Degree or Diploma Date

College: Name and Location:

Did you graduate? Yes No    Degree or Diploma Date

Trade, Business, Vocational Training, Other: Name and Location:

Did you graduate? Yes No    Degree or Diploma Date

Are you known to schools/references/employers by another name? Yes No

If yes, please indicate the name(s):

Have you ever been convicted of any misdemeanor or felony? (this includes, without limitation, pleading guilty, pleading no contest, or having a judicial finding of guilt)

Yes No

If yes, provide where, for what, and give dates:

List any special skills or training you feel we should be aware of in considering your application:

LICENSES, REGISTRATION OR CERTIFICATION

Do you have a current nursing, medical technologist or physician license, registration or certification?

Yes No

If Yes, please detail:

• the type of license/registration/certification

• the state(s) where you are licensed/registered/certified

• the expiration date of the license/registration/certification

Have you ever had your license, registration or certification suspended, revoked or terminated? Yes No

If yes, please identify: the license, registration or certification involved; whether it was suspended, revoked or terminated; the date such action took place; the state involved; and the length of time the license was suspended, revoked or terminated:

If you have a digital version of your resume you would like to send, attach it through regular e-mail by clicking here.

After submitting, if you need to return to the form to make a correction, please click on the back button on your browser, and not the "return to form" option as it will reset the form and clear your responses.

APPLICANT STATEMENT

1. I hereby certify that all responses set forth during my employment application process are true and complete. I understand and agree that any falsification, misrepresentation, or omission either on the employment application form or in my responses to questions asked during the interviewing or examination process may disqualify me from further consideration for employment, or if employed by Providence Medical Group, Inc. ("PMG") or Providence Health Partners ("PHP"), will subject me to immediate termination, whenever the falsification or omission is discovered. In this regard, where an item is left blank on the employment application, it is because there is no information within its scope.

2. The submission of this application authorizes PMG and PHP or their authorized agents to conduct a thorough investigation of all statements, written and oral, made by me during the employment application process, including without limitation, information concerning my employment positions, law enforcement record, driving record, and educational background. I hereby authorize all persons, companies or other entities connected with any such informational request, including without limitation, current or prior employers and law enforcement agencies to provide any and all information they may have regarding me or my employment. I release and agree to indemnify PMG and PHP, their authorized agents, and its employees, and all other persons, companies, and other entities from any and all liability arising out of such investigation, including without limitation, any liability for furnishing information or for taking any action based on the information provided.

3. I understand that a drug and/or alcohol screen may be required before and during my employment. In addition, I authorize a medical examination, including a drug and/or alcohol screen, by an examiner selected by PMG or PHP if I am made a contingent offer of employment. I release and agree to indemnify PMG and PHP, their authorized agents, and its employees, and all other persons, companies, and other entities from any and all liability arising out of any medical examination or drug/alcohol screen or for the taking of any action based on the results of any medical examination or drug/alcohol screen.

4. I agree and consent that PMG and PHP may inspect any PMG and PHP property at any time and for any reason, without notice. This property includes, without limitation, work stations, computers, offices, desks, lockers, voice mail, and filing cabinets. Additionally, I agree and consent that any personal items I bring onto PMG's or PHP's premises are subject to inspection at any time and for any reason, without prior notice.

5. I certify that I am a citizen of the United States, or, if not, I can provide required documentation permitting me to work in the United States.

6. I understand and agree if I am employed by PMG or PHP, my employment is at-will so that I may terminate my employment at any time and for any or no reason. Likewise, PMG or PHP can terminate my employment at any time and for any or no reason. I also understand and agree that nothing contained in PMG's or PHP's employment application or in the granting or conducting of an interview or anything set forth in any oral or written statement, communication, or policy now or in the future constitutes or creates or is intended to constitute or to create a contract or promise between me and PMG or PHP for employment, hours of work, or for the providing of benefits. Moreover, I acknowledge that PMG or PHP may modify, revoke, suspend, terminate, or change any or all of its plans, policies, or procedures at any time, without prior notice. No promises or guarantees regarding employment, hours of work, or for the providing of benefits have been made to me. I further understand and agree that no such promise or guarantee is binding on PMG or PHP unless it is in writing signed by me and the Chief Executive Officer of PMG or PHP, and that document states that the employment relationship is not "at-will" and details the specific promise or guarantee.

7. READ CAREFULLY BEFORE SUBMITTING. In consideration of PMG's or PHP's review of my application, I knowingly agree and understand that any claim or lawsuit arising out of my application for employment with, my employment with, or subsequent separation from PMG or PHP must be filed no more than one hundred and eighty (180) calendar days after the date the employment action that is the subject of the claim or lawsuit. While I understand that the statute of limitations for claims or actions arising out of an employment action may be longer than one hundred and eighty (180) calendar days, I agree to be bound by the one hundred and eighty (180) calendar day period of limitations set forth herein, and I waive any STATUTE OF LIMITATIONS TO THE CONTRARY.

I have read and understand the contents of this employment application and am fully able and competent to complete it.