Employment Application

Position(s) Desired
(1)
(2)
(3)
 
Personal Data
Name (First):
(Middle):
(Last):
Telephone #:
Address:
City:
State:
Zip:
 
Email Address:
 
How did you hear about us?
Friend
SRHC Website
Other Website, please specify
Radio Commercial
Newspaper Ad, please specify city
Other Publication Ad, please specify
Other, please specify
Check all types of employment you will consider:
Full-Time
Part-Time
Temporary
On-Call/PRN
Summer
Check all shifts you are willing to work:
Day
Evening
Night
Weekend
Holiday
Salary desired:
Date available to work:
 
Have you ever been found guilty, pled no contest, had a conviction for any felony or misdemeanor?
No     Yes
If yes, explain:
 
Have you ever been debarred or excluded from participation in Medicare, Medicaid, or any other federal or state funded health care program and have not been convicted of a health care related criminal offense?
No     Yes
 
Are you either a US citizen or an alien authorized to work in the United States?
No     Yes
 
Are you 16 years of age or older?
No     Yes
 
Educational Data
High School Name:
City, State:
Highest Grade Completed:
Did you graduate?
No     Yes
 
(1) College or Other School Name:
City, State:
Did you graduate?
No     Yes
Diploma, Degree or Certification Received:
 
(2) College or Other School Name:
City, State:
Did you graduate?
No     Yes
Diploma, Degree or Certification Received:
 
(3) College or Other School Name:
City, State:
Did you graduate?
No     Yes
Diploma, Degree or Certification Received:
 
Do you have a License, Registration and/or Certification that Relates to this Position?
(All information will be verified by Primary Source) No     Yes
If yes, complete this section:
License/Cert. #:
License/Cert. #:
License/Cert. #:
License/Cert. #:
Expiration Date:
Expiration Date:
Expiration Date:
Expiration Date:
 
List other Knowledge, Skills and Abilities which would qualify you for employment for the positions for which you are applying:
 
Employment History
Have you ever applied for a position at Salina Regional Health Center?
No     Yes         If yes, when?
 
Have you ever been employed by Asbury / St. John's / Salina Regional Health Center?
No     Yes         If yes, when?
 
Salina Regional Health Center does not permit relatives to supervise one another. In accordance with this policy, are there any departments you would not be able to work in?
No     Yes
If yes, please list the names, relationship and respective departments of those relative:
(Name, Relationship, Department, repeat as needed)
 
Under what other name(s) have you previously been employed or attended school?
 
List previous names (maiden name, nickname) here, if you were known by a different name.
 
Former Employers
Please list your last three employers, beginning with the most recent.
(1) Employer / Company:
Address:
City:
State:
Zip:
Phone number:
Position You Held:
Department:
Immediate Supervisor
 
Starting Date:
Salary:
Date Left:
 
Duties and / or Accomplishments:
Reason for Leaving:
May we contact for a reference?
No     Yes
 
(2) Employer / Company:
Address:
City:
State:
Zip:
Phone number:
Position You Held:
Department:
Immediate Supervisor
 
Starting Date:
Salary:
Date Left:
 
Duties and / or Accomplishments:
Reason for Leaving:
May we contact for a reference?
No     Yes
 
(3) Employer / Company:
Address:
City:
State:
Zip:
Phone number:
Position You Held:
Department:
Immediate Supervisor
 
Starting Date:
Salary:
Date Left:
 
Duties and / or Accomplishments:
Reason for Leaving:
May we contact for a reference?
No     Yes
 
Attach Your Resumé:
Resumés must be in one of the following formats: Microsoft Word (.doc),
Microsoft Works (.wps), Rich Text Format (.rtf), Text (.txt), or Acrobat (.pdf) and under 2MB.
 
Statement for Job Application
Salina Regional Health Center (SRHC) provides equal employment opportunities to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability, or status as a disabled veteran in accordance with applicable federal laws. In addition, SRHC complies with applicable state and local laws governing non-discrimination in employment in every location in which SRHC has facilities.
 
I hereby certify that the information given by me on this application is true and complete to the best of my knowledge and agree that falsified information or significant omissions may disqualify me from further consideration for employment and will be considered justification for dismissal is discovered at a later date. I further understand that a violation of fraud/abuse or misconduct in relation to Federal Healthcare Programs may disqualify me from further consideration for employment and will be considered justification for dismissal if discovered at a later date.
 
I understand that this employment application and any other Health Center document or agreement, either written or oral, are not contacts of employment. Employment may be terminated by either party at any time for any reason. I also understand that any offer of employment will be contingent on the following: proof of eligibility for employment as required by the Immigration Reform Act, satisfactory completion of a criminal background check, and satisfactory completion of a health assessment which will include drug and alcohol screening.
 
I authorize current and previous employers, personal references, schools and organizations named in this application to provide SRHC with any relevant information that may be required to arrive at an employment decision, including but not limited to, dates of employment, wage history, job description and duties, pay rate upon termination, written employment evaluations, and reasons for termination from service. I herby indemnify, release and hold harmless SRHC, all current and former employers, schools and organization and their agents, employees, assigns of and from any and all liability resulting from any and all truthful responses given to SRHC as part of this investigation. I agree that, as to former employers and their agents, employees and representatives, such persons shall be immune from liability pursuant to the provisions of K.S.A. 44-119a, as amended from time to time.
 
I agree and understand all of the above.
No     Yes