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Full Name:

Address:

Phone:

Email:

Professional License:

Employment Desired:

How did you hear about this position?

Date available for work:

Desired Hours:

Education (High School):

Education (Undergraduate College):

Education (Graduate College):

Education (Other):

List any seminars, classes, or other education not listed above which may help qualify you for this position:

Current Employer:

Current Employer Address:

Current Employer Phone Number:

Job position(s) at Current Employer:

* Wage at Current Employer :

What value did you add to this company or its customers?

* Dates of Employment:
To

May we contact your current employer?
Yes No

* References #1 Name:

* References #1 Occupation:

* References #1 Company Name:

* References #1 Address:

* References #1 Phone:

* References #1 Email:

* References #1 Relationship & years acquainted:

* References #2 Name:

* References #2 Occupation:

* References #2 Company Name:

* References #2 Address:

* References #2 Phone:

* References #2 Email:

* References #2 Relationship & years acquainted:

Additional Information:

Languages other than English?

Formal Job Training:

Skills:

If you are hired what value would you add to our company?

Describe what you believe are the most unique features of your work history:

Have you ever been employed with this Republic County Hospital or any other Great Plains Health Alliance facility before?
Yes No

If above is yes, when?:
To

Do you have any friends or relatives employed by Republic County Hospital?
Yes No

If above is Yes, please provide their names and relationship to you:

Are you currently employed?
Yes No

If you are under 18 years of age, can you provide proof of your eligibility to work?
Yes No

If hired, can you provide proof of U.S. citizenship or proof of your legal right to work in the U.S.?
Yes No

Are you able to perform all of the essential functions of the job for which you are applying with or without reasonable accomodation?
Yes No

If hired, are there any accommodations the company would need to provide so that you can perform all those essential functions and duties of the position being applied for?
Yes No

If above is Yes, please explain:

If driving is a requirement of the position applied for, have you in the last 7 years been convicted of Driving Under the Influence (DUI)?
Yes No

If hired, do you have a reliable means of transportation?
Yes No

If hired, would you be able to travel or work overtime as needed?
Yes No

Have you ever been convicted of a felony or misdemeanor?
Yes No

If above is Yes, please explain:

Have you ever been excluded from participation in any Federal Healthcare Program?
Yes No

If above is Yes, please explain:

I understand that a criminal record does not constitute an automatic bar to employment and will be considered only as it substantially relates to the job in question.
Yes No

* Republic County Hospital is an Equal Opportunity Employer. I certify that all the information given on this application is true and complete to the best of my knowledge. I give Republic County Hospital the right to investigate my past employment, and release liability from all entities providing such information. I consent to take a pre-employment drug screening.
Yes No