Current Positions Open

Full-time benefits include Medical, Dental, and Life Insurance, Options for AFLAC, and Retirement, Vacation and Sick Benefits.
Part-time benefits include Sick Benefits, Life Insurance, Options for AFLAC, and Retirement.
​You can pick up an application at the Office in the Healthcare Center, Fill out the form below,  or download the application and return it to the Healthcare Center Office. You may also email it to the appropriate Department Head for the position you are applying for (Check Directory for appropriate E-mail Address). For questions or more information please call 719-324-5262.

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Walsh Hospital District Application for Employment Form

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Personal Information

Date:

Last Name:

First Name:

Middle Initial:

Are you atleast 18 Years Old?

Yes

No

Home Phone #:

Cell Phone #:

Present Address:

Present City:

Present State:

Present Zip Code:

Email Address: (additional employment forms will be sent to this email)

Business for Which You Are Applying:

Walsh Healthcare Center (Long Term Care NH)

Maplewood Homes (Assisted Living)

Walsh Medical Clinic

Walsh Ambulance Service

Position(s) for Which You Are Applying:

Laundry Dept.

Housekeeping Dept.

Dietary Dept.-Cook

Dietary Dept-Dishwasher

Administration

Maintenance Dept.

Registered Nurse (R.N)

Licensed Practical Nurse (L.P.N )

Certified Nurses Aide (C.N.A )

Medical Assistant

Nurse Practitioner

Office Receptionist

Primary Care Provider(PCP)

E.M.T

Type of Position:

Full Time

Part Time

PRN

Temporary

Shift: (Nursing Dept.)

Day

Evening

Night

Weekend

Rotation

Salary Requirement:

Date Available for Work:

Are You Legally Authorized to Work in the U.S?

Yes

No

How did you learn about this position?

Newpaper Ad

Facebook

Internet

Job Posting

School

Current Employee

Other

Are you able to perform the essential, job related functions of the position for which you are applying with or without reasonable accommodations?

Yes

No

Describe any accommodations necessary:

Have you ever been convicted of a crime?

Yes

No

If yes, please give date, place and nature of each such crime.

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Educational History

High School Name:

City:

State:

Last year attended in school:

9

10

11

12

Graduated/GED:

Yes

No

College Name:

City:

State:

Last year attended in school:

1

2

3

4

Graduated:

Yes

No

Date Graduated:

Degree or Certificate:

School Name:

City:

State:

Last year attended in school:

1

2

3

4

Graduated:

Yes

No

Date:

Degree or Certificate:

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Licenses, Registrations and Certifications

List any professional licenses, registrations or certifications you possess.

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Previous Employment: List most recent or current first

From Date:

To Date:

Company Name:

Address:

Immediate Supervisor:

Phone Number:

May We Contact Them?:

Yes

No

Name While Employed:

Job Title:

Type of Position/Hrs per week/Salary:

Nature of Duties:

Reason for Leaving:

From Date:

To Date:

Company Name:

Address:

Immediate Supervisor:

Phone Number:

May We Contact Them?:

Yes

No

Name While Employed:

Job Title:

Type of Position/Hrs per week/Salary:

Nature of Duties:

Reason for Leaving:

From Date:

To Date:

Company Name:

Address:

Immediate Supervisor:

Phone Number:

May We Contact Them?:

Yes

No

Name While Employed:

Job Title:

Type of Position/Hrs per week/Salary:

Nature of Duties:

Reason for Leaving:

From Date:

To Date:

Company Name:

Address:

Immediate Supervisor:

Phone Number:

May We Contact Them?:

Yes

No

Name While Employed:

Job Title:

Type of Position/Hrs per week/Salary:

Nature of Duties:

Reason for Leaving:

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References: List two personal references not related to you, whom you have known at least one year.

Name:

Phone Number:

Company Phone Number:

Relationship:

Name:

Phone Number:

Company Phone Number:

Relationship:

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Upon submitting this application form you will receive additional employment application forms to fill out via the E-mail provided. We will not be able to proceed with your application until these forms are completed and signed. Make sure your E-mail Address provided is correct.

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

Date: (required)

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