Date:
Desired Place of Employment: Choose a location Memorial Community Hospital Blair Clinic Fort Calhoun Clinic Cottonwood Clinic Home Health and Hospice

Personal
Full Name (last, first middle):
Mailing Address:
City, State ZIP:
Phone:
Phone for Messages:
Social Security Number:
Are you 16 years of age or over? Yes No
If under 21, age:
Position(s) applying for:

Salary Expectations:
SPECIFY HOURS AVAILABLE each day/night: Full Time Part Time On Call Temporary
Hours per week:
Minimum
Maximum
Have you worked under another name(s)? Yes No
If yes, list name(s):
Have you ever worked for any of the companies identified at the top of this application? Yes No
If yes, which company? Choose a location Memorial Community Hospital Blair Clinic Fort Calhoun Clinic Cottonwood Clinic Home Health and Hospice Dates: From To

Do you have any relatives employed with any of the companies identified at the top of this application?
Yes No
If yes, who? Relationship:
Which Organization?

Are you a citizen of the United States or specifically eligible to work in the United States? Yes No

Have you ever been convicted of a violation of the law other than a minor traffic violation? Yes No
If yes, Date Convicted:
If yes, explain and give details:

A conviction record will not necessarily disqualify an applicant from employment. The circumstances of a conviction will be considered in relation to the nature of the job for which you apply.

Education/Training

Office Skills: (Check all that apply)
Typewriter/WPM Medical Terminology Word Processor Transcription
Data Entry 10 Key Microsoft Windows Microsoft Word Word Perfect
Microsoft Excel Access
Please list any additional skills and qualifications that may relate to the job for which you are applying:


Have you had any military service related to the job for which you are applying? Yes No
If yes, please give details (Branch, Rank, Dates, Duties).

Professional Licenses, Registrations and/or Certifications
(RN, LPN, CNA, CDL, DOT, Engineer, Etc.)

State Issued: Expiration Date:
Type: License/Certificate Number:
Other State(s): License/Certificate Number:
If not currently licensed, have you applied? Yes No Date Applied:
Certification: Date Received:
Has your professional license ever been suspended, revoked or limited in any way? Yes No
Has your license ever been on probationary status? Yes No
Reason:

Have you ever been subject to exclusion or penalties from Medicare as a participating provider? Yes No
If yes, explain and give details:

Experience
Please give a complete record of all employment. Start with the most recent employment.

COMPANY NAME: Telephone:
Address: Supervisor/Title: May we contact? Yes No
Employed From: To: Hours per week:
Rate of Pay: $
State job title and describe your work:

Reason for leaving:
What did you like most about this job?
What did you like least about this job?

COMPANY NAME: Telephone:
Address: Supervisor/Title: May we contact? Yes No
Employed From: To: Hours per week:
Rate of Pay: $
State job title and describe your work:

Reason for leaving:
What did you like most about this job?
What did you like least about this job?

COMPANY NAME: Telephone:
Address: Supervisor/Title: May we contact? Yes No
Employed From: To: Hours per week:
Rate of Pay: $
State job title and describe your work:

Reason for leaving:
What did you like most about this job?
What did you like least about this job?

COMPANY NAME: Telephone:
Address: Supervisor/Title: May we contact? Yes No
Employed From: To: Hours per week:
Rate of Pay: $
State job title and describe your work:

Reason for leaving:
What did you like most about this job?
What did you like least about this job?

Professional References
List at least two persons who have knowledge of your skills and character.

Name: Telephone:
Street Address: City: State: Zip:

Name: Telephone:
Street Address: City: State: Zip:

How were you referred to MCH Health System? Please choose one Walk In Newspaper advertisement Former employee Career fair Radio Employee referral School Temporary service Internet Other
If employee referred, please identify:
If newspaper, radio, television, please identify:

Please Read Carefully Before Signing
I understand that any false statements on this application or any other form that I complete shall be sufficient cause for rejection for employment or immediate discharge when discovered.

I understand that if I accept a position with an affiliate of MCH Health System, my employment will be governed by all applicable policies and procedures as outlined in the MCH Health System and affiliate specific policy and procedure manual(s) and handbook. In addition, I understand that these policies and procedures may change periodically, and the handbook will be updated on an as-needed basis. It is my responsibility to remain informed on any and all such changes.

I hereby authorize this company to provide information regarding my employment to persons who have legitimate interest in the information.

I hereby authorize release of any and all information regarding my employment to assist in determining my suitability for employment.

I understand that this application is not a contract of employment. I understand that if I receive an offer of employment, it would be a conditional offer of employment, expressly subject to meeting the physical requirements of the job, which, depending on the organization, may include a post offer physical, drug test and background investigation. I further understand that my employment would be at will, that is, I would reserve the right to terminate my employment when I choose, and my employer would reserve the same right.

Signature of Applicant: _________________________________________________________ Date:

EEO Voluntary Information
COMPLETION OF INFORMATION BELOW IS VOLUNTARY
We consider all applicants for positions without regard to race, color, religion, sex, national origin, age, mental or physical disabilities, veteran/national guard or any other similarly protected status.

To be completed by applicant on a voluntary basis. Not for interview purposes. To be filed separately from application.

In an effort to comply with requirements regarding government record keeping, reporting and other legal obligations which may apply, we invite you to complete this applicant data survey. Providing this information is STRICTLY VOLUNTARY. Failure to provide it will not subject you to any adverse personnel decision or action. Your cooperation is appreciated.

Please be advised that this survey is not part of your official application for employment. It will not be used in any hiring decision. The information will be used and kept confidential in accordance with applicable laws and regulations.

Male Female

Please check one of the following Equal Employment Opportunity Identification Groups:
White (not of Hispanic origin) Black (not of Hispanic origin) Hispanic
American Indian/Alaskan Native Asian/Pacific Islander

We greatly appreciate your interest. Only the most qualified candidates will receive a response. We are an Equal Opportunity Employer and do not discriminate because of race, creed, ancestry, color, religion, sex, national origin, age, marital status, veteran status or disability. Your application will remain under active consideration for 60 days.