Contact Us
Mountainview Home Health, LLC
409 N. Second Street
Yakima, WA 98901
(509) 576-0800
Qualified applicants receive consideration for employment without discrimination based on age, creed, marital status, national origin, race, gender or sexual orientation, or the presence of any sensory, physical, or mental disability, veterans status, or any other basis prohibited by federal, state, or local laws.

INSTRUCTIONS:Please complete all information requested on his form. Please type or print clearly. If you wish to supply additional education or work history information, attach a separate sheet. Submitting an application for employment does not guarantee an interview. A resume is optional and is not considered a substitute for any section of the application.

How did you hear about this position?
Have you any relatives employed here?
Have you been previously employed here?
Are you a U.S. citizen or legally authorized to work in the U.S.?
Proof of identify and eligibility to work will be required if you are hired.
Have you been debarred, excluded or are otherwise ineligible for participation in Medicare, Medicaid, or other government payor programs?
Were you ever discharged for cause, dismissed during probation or have you resigned under pressure or unfavorable circumstances?
Have you ever been convicted of a criminal offense or been released from prison?

Job Information

Are you willing to work weekends
On Call after hours (RN)

Professional Registration

If you don’t have a required registration or license, have you applied for one
If you are not licensed in Washington State, have you applied for reciprocity?
Have you ever had a professional registration/license revoked, suspended or restricted?

Education Information

Skill Abilities Training

Job Performance Ability

Given your knowledge, skills, education and experience are you able to perform all the essential functions of the position for which you are applying, with or without reasonable accommodation?
Is there any reason you might be unable to meet our work attendance requirements?

Employment History

Have you, within the last 12 month, been employed by an agency or organization which serves as a Medicare fiscal intermediary or carrier

Professional References (other than relatives)

Professional References (other than relatives)

I hereby certify that the facts set forth in this employment application are true and complete to the best of my knowledge. I agree that if I am employed and the information is found to be false in any respect, I will be subject to dismissal without notice at any time. I understand that my employment will be contingent upon proof of citizenship or alien registration, and upon the checking of references.

In consideration of my employment, I agree to conform to the rules and regulations of Mountainview Home Health, LLC. I understand that my employment and compensation can be terminated with or without notice at anytime, at the option of either the company or myself.

I understand that no manager or representative, other than the CEO or Governing Board, has any authority to enter into agreement contrary to this. Any agreement for employment for any specified period of time with the CEO or Governing Board must be in writing and signed.

I consent and authorize Mountainview Home Health, LLC and its personnel to investigate all information concerning my previous employment, education and background including records of law enforcement, federal and state agencies. Iauthorize the Registrar/Placement Office of all educational institutions attended to release in official copy of my transcript, and, if available, faculty appraisals. I authorize any appropriate licensing board to release full information concerning my licensure status and licensure history. I authorize any prior employers to provide such information concerning my employment with them as may be requested. I therefore release all parties and persons connected with any request for information from all claims, liabilities and damages, for whatever reason arising out of furnishing said information.

I understand that if offered a position with Mountainview Home Health, LLC, I will be required to submit to a background check as a condition of employment. I understand that unsatisfactory results from, refusal to cooperate with or any attempt to affect the results of this pre-employment check will result in withdrawal of any employment offer or termination of employment if already employed. By submitting the Application for Employment, I hereby consent to said check.

If employed, I further agree that if Mountainview Home Health, LLC advances any paid leave before it has been accrued, or advances or loans me any money during the course of my employment, or I am indebted to the company at the time my employment ends, or if I lose, damage or fail to return any company property, I authorize the company to deduct from my wages sufficient funds to repay such loans, advances, indebtedness, or to replace its property in order to satisfy any unpaid obligations.

This application for employment will be kept in an active file for six calendar months. During this period, an individual will be considered for the job in which he/she indicated an interest on this application, subject to existing vacancies.

After the six calendar month period, all applications will be placed in an in-active file and will not be used for hiring purposes Any individual may continue to reapply at the company every six months to maintain his/her status in the active file.

Disclosure Statement

Have you ever been convicted of any of the following crimes against children or other persons:
Dependency action to have neglected or sexually assaulted/abused or exploited any minor or adult person or to have physically abused any minor?
Domestic relations proceeding to have sexually abused or exploited any minor or to have physically abused a minor?
Disciplinary board final decision to have neglected or sexually or physically abused or exploited any minor or adult person?
Court or State licensing board action to have neglected or sexually abused or exploited any minor or adult person?
Discip1inary board final decision to have abused or financially exploited any person 60 years or older who has a functional, mental or physical inability to care for himself or who is a patient in a state hospital?
Protection proceeding under Chapter 74.34 RCW to have abused or financially exploited a person 60 years of age or older who has a functional, mental or physical inability to care for himself or herself who is a patient in a state hospital?
Has it been determined by any state agency or department that you have abused, neglected or Exploited anyone?
Has a court issued any order of protection against you for abuse or exploitation?
Have you ever had a license to care for children or adults denied, revoked or suspended?
First, Second or third degree Extortion
First, Second, or Third degree Theft
First or Second degree Robbery
Or any of these crimes as they may have been renamed
UNDER PENALTY OF PERJURY, I certify that the above information is true, correct, and complete. I understand that ifI am hired, I can be discharged for any misrepresentation or omission in the above statement. I also understand that if I am hired, my employment is conditioned on your receipt of a satisfactory report from the Washington State Patrol, lntellicorp & other states.

You will be notified of the State Patrol’s & Intellicorp’s responses within ten days after we receive the report. We will make a copy of the report available to you upon your request.