Job Application

Personal Information

General Information

If hired, you will be required to provide documentation verifying citizenship or eligibility to work in the U.S.

Position Information

Complete ONLY if you are applying for a position in which you will be driving during work hours.

Education Information

Include high school training and courses of study

Include technical, vocational, business, or military training

Include college or university training and courses of study

Include only graduate level training and courses of study


List any relatives currently working at Black River Memorial Hospital:

Professional Licenses & Registrations

Employment History

Present or Last Employer

Previous Employer

Previous Employer

BRMH Reference Checking Process

A Member of the Human Resources department will notify you, that we would like to begin checking your references.

An e-mail will be sent to you from Skill Survey that includes a link to their website.

You will need to enter the e-mail addresses of five (5) work-related references, including a minimum of two (2) current or previous supervisors or managers. If unable to enter this information within 48 hours, please contact Human Resources at (715) 284-5361.

Each of your references will receive an e-mail from you via SkillSurvey directing them to complete a confidential on-line survey regarding your past work performance.

To help expedite the process, we recommend that you contact your references in advance and encourage them to complete the on-line survey in a timely manner, ideally within 48 hours.

You should monitor the progress being made by your references by accessing the SkillSurvey website. Please contact those individuals who have not yet completed the reference survey.

Completed references are a tool used to evaluate and select the best candidate. Job offers are not extended to any candidate without completed references.

Please Read Carefully and Sign

DRUG TESTING POLICY: Black River Memorial Hospital is committed to maintaining an environment which is free from the influence of illegal drugs and alcohol to protect the health, safety and well-being of our patients, employees, and visitors. We reserve the right to test for the presence of illegal drugs in situations where a reasonable suspicion of usage exists as well as post-offer, pre-employment.

I understand that the information on this application has been requested for the purpose of evaluating my qualifications for employment. This application and any other documents presented to me in the course of applying for a position with Black River Memorial Hospital is not a contract or promise of employment. I also understand that if I am hired, I will be an employee at will, which means that I may leave my employment voluntarily at any time for any reason. I understand that any oral or written statements to the contrary are not binding on Black River Memorial Hospital and that I may not rely upon them.

I authorize all schools and other educational institutions I have attended to provide Black River Memorial Hospital with all information which it seeks related to the dates of my attendance, the degrees I have named, the courses I have taken, my grades and related matters. I waive and release any and all claims I may have against these institutions as a result of their compliance with Black River Memorial Hospital's request.

I agree to any and all pre-placement assessment(s) as may be deemed necessary by Black River Memorial Hospital, and further understand that my employment is contingent upon my completion of the hospital pre-employment assessment.

I understand that any false statements, omission of facts or misrepresentations in connection with my application form may be sufficient cause, in and of itself, to disqualify me for employment or cause my dismissal from employment whenever discovered.

I further understand that my employment is contingent upon providing proof of eligibility to work in the United States.

Click here to read the Employee Standards of Conduct (opens in a new window) and then check the box below.

Predictive Index®

Black River Memorial Hospital's mission is to serve you with excellence. In order to accomplish the organization's mission, we strive to recognize the value of each individual employee while promoting and encouraging a team approach to challenges and opportunities. We acknowledge the uniqueness of each employee and strive to create a positive work climate for employees, teams, departments and the organization. One tool to help us meet our mission is the Predictive Index®.

What Does the PREDICTIVE INDEX® Do and Not Do? The Predictive Index® is a method to predict the usual way in which people behave and identify their motivating needs. The Predictive Index® does not measure education, experience or skills. Nor does it examine values, aptitudes or pathologies.

The Predictive Index® was developed and validated in compliance with Equal Employment Opportunity Commission (EEOC) Guidelines, as well as the professional standards established by the American Psychological Association (APA) and the Society of Industrial & Organization Psychology (SIOP).

Why Does Black River Memorial Hospital Use Predictive Index®? At Black River Memorial Hospital, the Predictive Index® survey is used as one tool to match the right person to the right job, facilitate communication, augment coaching activities and enhance teamwork. People happen to work differently. The Predictive Index® is not about identifying "good" or "bad", it is about identifying differences and using those differences to the organization, manager and employee's benefit

Organization Survey Checklist

DIRECTIONS: Please read the words in the list below and check those that you feel describe the way you are expected to act by others.

Organization Survey Checklist

DIRECTIONS: Continue by reading the words in the list below, now checking those that you yourself believe really describe you.


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