Date:
Last:      First:      Middle:

Address
Street:      City:      State:      Zip:

Contact Information
Telephone:      E-mail Address:

Are you under age?     Yes      No

If Yes, can you furnish a work permit (SS Card, Birth Certificate) if required?     Yes      No

Have you had a misdemeanor or felony conviction?     Yes      No

If Yes, please explain the nature of the conviction(s), when, and where it occurred.
A conviction record will not necessarily be a bar to employment.  Factors such as age and time of the offense, the seriousness and nature of the violations, and the applicant's rehabilitation will be considered in the hiring decision.

Have you been sanctioned for Medicare or Medicaid Fraud or Abuse?    Yes      No
If Yes, please explain:

Employment Information
 
Position applying for:
Employment Type Desired:     Full Time      Part Time      Temporary     Call-In

Shift Preferred:     Day      Evening      Night      8-hour     12-hour

Are you able to work weekends and holidays?     Yes      No

Are you able to meet the attendance requirements? Yes      No

Have you worked for this facility before? Yes      No
If yes, under what name?

Are you related to or living in the same household with any person(s) currently employed by this facility? Yes      No
If yes, please state person(s) name(s):

Are you presently employed? Yes      No
If so, may we contact your present employer? Yes      No

Education

High School
School Name:      Location:      Years Completed:

College

School Name:      Location:      Years Completed:
Course of Study:      Degree Earned:

Technical/Other

School Name:      Location:      Years Completed:
Course of Study:      Degree Earned:

Registered, Licensed, and Certified Nursing Applicants Complete This Section

RN      BSN      MS      Diploma      Associate      Degree
Kansas License? Yes      No
Kansas License/Certification Number?
Expiration Date?

Other Medical Registered, Licensed or Certified Applicants Complete This Section

License, Registration/Certification Number:
Expiration Date:
Are you currently licensed, registered or certified in Kansas? Yes      No
License, Registration or Certification Number:
Expiration Date:

Former Employers, List Last Four Employers; Start with the Last Employer First

Month/Year                Employer Name/Address        Salary                Position                            Reason for Leaving

From
                           

To

From
                           

To

From
                           

To

From
                           

To

Personal References

Name Address Phone Number Years Known
Name Address Phone Number Years Known
Name Address Phone Number Years Known
Name Address Phone Number Years Known

Other Skills and Qualification
Summarize any job-related training, skills, certificates, and/or other qualifications

I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references.  I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions and all other person or organizations for providing such information.  In signing this application for employment, I clearly understand and agree that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed,, whenever it may be discovered.  If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment.  Accordingly, either the employer or I can terminate the relationship at will, with or without cause, at any time, with or without notice.  I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired  Failure to submit such proof within the required time shall result in immediate termination of employment.  I will consent to any and all examinations required by the facility, including drug and alcohol testing.  I authorize this firm to make any lawful investigation, including criminal background checking.  If hired, I will abide by all Company rules, regulations and Code of Conduct and Compliance.  Upon my termination, the facility may release reference information on my work.

By clicking the button below, I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.

Signature
    Full Name:
            Date:

For more information, please contact:
Robyn Medina
Director of Human Resources
Stevens County Hospital
1006 S. Jackson
Hugoton, Ks  67951
E-mail:  hrsch@pld.com
Phone:  620-544-6141
Fax:  620-544-7822