| Position Applied For: |
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| Date: |
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| First Name: |
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| Last Name: |
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| Address Street 1: |
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| Address Street 2: |
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| City: |
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| State: |
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| Zip Code: |
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| Daytime Phone: |
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| Evening Phone: |
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| Soc. Sec. # |
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| Email: |
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| Are you under the age of 18, Yes or No? |
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| Are you legally able to be employed in the United States, Yes or No? |
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| Have you been convicted of a crime excluding misdemeanors, summary offenses, Yes or No? |
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| Have you been convicted of a controlled substance violation, health care fraud or patient abuse violation, Yes or No? |
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| If yes to either of the preceding two questions, please explain: |
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| Can you safely perform the essential functions of the position for which you are applying, Yes or No? |
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| Have you ever been employed with Decatur Health Systems, Yes or No? |
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| When? |
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| Where? |
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| Are members of your immediate family employed within the department of the position desired, Yes or No? |
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| CPR Certified? Specify Month/Year of Certification |
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High School Education:
Provide Name and Address of All Schools Attended |
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State number of High School years completed,
1, 2, 3 or 4 Years? |
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College Education:
Provide Name and Address of All Colleges
Attended |
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State Number of College Years Completed,
1,2,3 or 4 Years? |
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Tech/Other Education:
Provide Name and Address of All Tech Schools |
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| Professional License/Certification Number: |
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| If applying for a position that requires certification or licensure, a copy of such license must be sent to Decatur Health Systems, 810 W. Columbia, PO Box 268, Oberlin, KS 67749 or FAXed to 785-475-2453, Attn. Human Resources Department. |
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Present or Last Employer:
Include
Name
Phone Number
Supervisor
Dates of Employment,
Current Wage Rate
and Reason For Leaving |
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Next Previous Employer:
Include
Name
Phone Number
Supervisor
Dates of Employment
and Reason For Leaving |
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Next Previous Employer:
Include
Name
Phone Number
Supervisor
Dates of Employment
and Reason For Leaving |
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Professional References:
Include
Name
Address
Phone Number
and Type of Professional Relationship |
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Personal References:
Include
Name
Address
Phone Number
Type of Relationship |
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| AGREEMENT: |
My responses are true and complete. I understand that falsification of information is sufficient cause for dismissal. In the event of employment, I agree that my employment with the facility is at will, which means that the facility has the right to discharge me for any reason whatsoever, or I have the right to terminate my own employment for any reason whatsoever. I understand that if I am offered a job, I will be required to undergo a physical examination with drug test, reference check, and criminal record check. I hereby authorize any physician, hospital, clinic, laboratory, and any other medical facility, as well as any previous employer, personal reference, and any city, state, or national criminal recordkeeper to furnish any infomation with reference to me as may be necessary. I also understand that, according to federal lawss, I may be asked to produce certain documentation to verify my citizenship status or legal authorization to work in the United States. Any offer of employment is contingent upon my ability to produce the required documentation within the time period required by law. This application shall be considered for a period of one year. |
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I have read the information in this agreement |
