Gothenburg Memorial Hospital

GOTHENBURG MEMORIAL HOSPITAL

APPLICATION FOR EMPLOYMENT

We consider applicants for all positions without regard to race, color religion, creed, gender, national origin, age, disability, marital or veteran

status, or any other legally protected status.

Please Print Application

Position Applied For Date of Application

Last Name First Name Middle Name

Address Street City State Zip Code

Phone Number(s) Social Security Number

Best time to contact you is: ………………………………………. __________ AM/PM

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

Have you ever filed an application or been employed by this organization? Yes No

If Yes, give date _________________

Do you have a friend or relative working at this organization? Yes No

Have you ever been convicted of a crime? Yes No

If yes, give date(s), offense(s) and Disposition

Are you currently employed? Yes No

May we contact your present employer? Yes No

Date you would be available for work ___/___/___ Desired salary range? ________

Are you available to work: ___Full-time, ___Part-time, ___Temporary

Are you available to work: ___Mornings, ___Afternoon, ___Evenings, ___Nights

Can you travel if a job requires it? Yes No

Education:

School	Name of School	Location	Years Completed	Dates To From	Course of Study	Diploma/ Degree
Elementary
High School
Trade
College
Graduate
Professional
Business
Other
List Health care, business or industrial equipment that you operate proficiently

SPECIALIZED TRAINING – Describe any job related training, credentialing, skills, recent continuing education, and computer experience, including dates if available.

Professional Licenses, Registration and/or certificates- Do Not Include Drivers License
Type	State Issued	Date Issued	Expires	Number	Eligible

EMPLOYMENT EXPERIENCE

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

1. Employer Dates Employed May we contact this employer?

_______________________________________ ___________________________ Y N

Address Pay Salary/Rate

_______________________________________ ___________________________

Phone Your Supervisor Your Job Title

_______________________________________ ___________________________ _________________________

Describe the work you performed

________________________________________________________________________________________________________

Reason for leaving

________________________________________________________________________________________________________

2. Employer Dates Employed May we contact this employer?

_______________________________________ ___________________________ Y N

Address Pay Salary/Rate

_______________________________________ ___________________________

Phone Your Supervisor Your Job Title

_______________________________________ ___________________________ _________________________

Describe the work you performed

________________________________________________________________________________________________________

Reason for leaving

________________________________________________________________________________________________________

3. Employer Dates Employed May we contact this employer?

_______________________________________ ___________________________ Y N

Address Pay Salary/Rate

_______________________________________ ___________________________

Phone Your Supervisor Your Job Title

_______________________________________ ___________________________ _________________________

Describe the work you performed

________________________________________________________________________________________________________

Reason for leaving

________________________________________________________________________________________________________

If additional space is needed, please list separately.

REFERENCES – Please list three references including name, address, and phone number.

ADDITIONAL CANDIDATE INFORMATION – In this section, you may state any other qualifications, summarize your experience, or convey any other information you would like us to consider.

Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the position for which you have applied? (You are aware of the activities involved in this position).

___Yes ___No

APPLICANT’S CERTIFICATION

I certify that all matters contained in this application are true and that any misleading or false statements would render this application void and would be sufficient cause for immediate dismissal in the event of employment.

I understand that this is an application for employment and that no employment contract is being offered.

I understand that my employment is at will, and that either party is free to terminate the employment relationship at anytime without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.

I hereby authorize Gothenburg Memorial Hospital to investigate all matters contained in this application and to contact prior employers to obtain any and all information related to my past work performance.

I agree, if employed, to abide by all Gothenburg Memorial Hospital rules and regulations. I understand that such employment is for an indefinite period of time and that the company can change wages, benefits and conditions of employment at any time.

I understand that I am required to immediately notify Gothenburg Memorial Hospital if any action is proposed to exclude me from participation in any federal or state Medicare, Medicaid or other third party payer program.

I have read and understand the above.

_________________________________ ____________________________

Signature Date

IMPORTANT NOTICE TO ALL APPLICANTS

If you are selected for employment you must be prepared to verify your eligibility to work as required under the Immigration Reform and Control Act of 1986. This requirement applies to all new employees including U.S. citizens, permanent to residents and nonimmigrant’s. You will have to provide documentation within 3 days of your hire date to verify your identity and eligibility to work.

GOTHENBURG MEMORIAL HOSPITAL

An equal opportunity employer