Chase County Community Hospital

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NOTICE TO APPLICANTS & EMPLOYEES: Screening tests for alcohol and drug use may be required before hiring and during your employment.

IMPORTANT: Chase County Community Hospital does not discriminate in hiring or employment on the basis of age, gender, color, race, religious creed, national origin, veteran status, marital status, ancestry, physical or mental disabilities, medical condition, pregnancy, or parenthood unrelated to the ability to perform the work required. No question on this application is intended to secure information to be used for any such discrimination. This application will be given appropriate consideration. However, its receipt does not imply that the applicant will be employed.

AN EQUAL OPPORTUNITY EMPLOYER.

Download an application in pdf format to print and send by mail.


		Personal Information
		Position applying for:			Salary Desired:

Shift:

Day

Eve.

Noc

PRN


		First Name:			Last Name:
		Middle Name:			Other Names Used:
		Present Address:			City:
		State:			Zip:
		Permanent Address:			City:
		State:			Zip:
		Phone:			Email:
		Pager #:			Social Security #:
		Date:			Date Available:


Have you ever been convicted of a felony?	Yes	No
If YES, explain below the nature of the offense, date and location.

If employed can you submit proof that you are at least 18 years of age?	Yes	No
Are you legally entitled to work in the USA?	Yes	No
After employment, can you provide proof of citizenship, visa, or alien registration?	Yes	No
List pertinent licenses to include CPR/certification, RN and CNA license number, expiration date.


Military Service:
Branch:	From:	To:
Rank:	Current:	Status:

Education & Training (List most recent first)


		1. High School, Colleges, Universities, Trade or Business School			City, State (List campus attended)
		Degree, Diploma			Major Area of Study
		2. High School, Colleges, Universities, Trade or Business School			City, State (List campus attended)
		Degree, Diploma			Major Area of Study
		3. High School, Colleges, Universities, Trade or Business School			City, State (List campus attended)
		Degree, Diploma			Major Area of Study

Work History (List most recent first)
Include paid or verifiable non-paid experience including military service. If you have had more than one position with the same employer, please list each position separately. It will help us process your application more quickly through our background verification check if you provide complete and accurate addresses of former employers.


		1.
		Job Title:			Type of Business:
		From (MO/YR):			To:
		HR/WK:			No. of Employees Supervised:
		Starting Salary:			Per:
		Final Salary:			Per:
		Supervisor's Name & Title:			Employer's Phone #:
		Company Name:			Complete Address:
		City:			State
		Reason for Leaving:			May we contact: (yes/no)
		Description of Duties:


		2.
		Job Title:			Type of Business:
		From (MO/YR):			To:
		HR/WK:			No. of Employees Supervised:
		Starting Salary:			Per:
		Final Salary:			Per:
		Supervisor's Name & Title:			Employer's Phone #:
		Company Name:			Complete Address:
		City:			State
		Reason for Leaving:			May we contact: (yes/no)
		Description of Duties:


		3.
		Job Title:			Type of Business:
		From (MO/YR):			To:
		HR/WK:			No. of Employees Supervised:
		Starting Salary:			Per:
		Final Salary:			Per:
		Supervisor's Name & Title:			Employer's Phone #:
		Company Name:			Complete Address:
		City:			State
		Reason for Leaving:			May we contact: (yes/no)
		Description of Duties:


		4.
		Job Title:			Type of Business:
		From (MO/YR):			To:
		HR/WK:			No. of Employees Supervised:
		Starting Salary:			Per:
		Final Salary:			Per:
		Supervisor's Name & Title:			Employer's Phone #:
		Company Name:			Complete Address:
		City:			State
		Reason for Leaving:			May we contact: (yes/no)
		Description of Duties:
		Explain any gaps in your employment as set forth:

For Clerical Applicants Only


		Do you type?			WPM
		Do you take shorthand?			WPM
		List the office equipment you operate. Elaborate on any skills.

References
List three job related references not related to you.


		1.
		Name:			Occupation of Title:
		Address:			City:
		State:			Zip:
		Phone:			Years Known:


		2.
		Name:			Occupation of Title:
		Address:			City:
		State:			Zip:
		Phone:			Years Known:


		3.
		Name:			Occupation of Title:
		Address:			City:
		State:			Zip:
		Phone:			Years Known:
		Present community and professional affiliations:


Have you ever worked for Chase County Community Hospital before?	Yes	No
If YES, state dates, location and position held:

Do you have any responsibilities or commitments that amy prevent you from meeting work and attendance requirements?	Yes	No
What prompted you to apply for a position with us? (friend, ad, agency, etc.)

Do you have any friends or relatives employed by any Chase County Community Hospital?	Yes	No
Please list their names and the locations they work at:

Additional information about yourself which will aid in evaluating your career interest and abilities:

		In making an application for employment with any Chase County Community Hospital, I understand and acknowledge the following: The information given by me on is true in all respects and I have not failed to disclose information which Chase County Community Hospital could consider relevant to its hiring decision. I understand that I may be refused employment or, if employed, terminated should misrepresentations be discovered. I voluntarily give Chase County Community Hospital the right to make a thorough investigation of my past employment activities, agree to cooperate in such investigation and authorize all persons, and companies to supply such information to Chase County Community Hospital. I consent to take the pre-employment physical examination, if offered employment, and such future examinations as may be required by Chase County Community Hospital as such times and places as Chase County Community Hospital shall designate. I understand that Chase County Community Hospital reserves the right to test for drug use of an applicant or employee at anytime. I understand that, if employed, my employment is for no definite period of time and is "at will" and no one other than the Chase County Community Hospital president has any authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to these terms and only if in writing. 5. Should I become employed with Chase County Community Hospital, I agree to conform to its rules and regulations and any modifications or amendments thereto including but not limited to its code on conduct. Also, I will preserve the strictest confidence of all information concerning the business of Chase County Community Hospital and patients. I further understand that Chase County Community Hospital follows the "fair employment practice code" and there is no discrimination in the hiring of individuals based on age, sex, race, color, religious creed, national origin, marital status, ancestry, physical or mental disabilities, or medical condition unrelated to the ability to perform the work required. STATEMENT OF CERTIFICATION - APPLICANT SIGNATURE by signing this application, I certify under penalty of law that the information provided anywhere in this application is true, correct and complete to the best of my knowledge and belief. I also acknowledge that should investigation at any time disclose any representation of falsification, my application may be rejected, my name be removed form further consideration, and I may be disqualified from further examinations and/or terminated from employment. I also authorize Chase County Community Hospital to make all necessary and appropriate investigations allowable by law to verify the information provided. I have read and understand the above and have had the opportunity to ask questions which, if asked, were satisfactorily answered.
		I Accept I Do not Accept

You must accept the terms before submitting your application.