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IApplication for Employment Rush County Memorial Hospital ~~- 8th & Locust -Box 520

La Crosse, Kansas 67548-0520 222-2545PLEASE PRINT

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.

Position(s) applied for _ Date of application __----'-1__1'-----__

Referral Source o Advertisement o Employee o Relative o Government Employment Agency

o Walk-in o Private Employment Agency o Other

Name of source (if applicable) _

Name _ LAST FIRST MIDDLE

Address STREET CITY STATE ZIP CODE

Telephone # ->-C__)'-- Mobile/Beeper/Other Phone # ....:.C__.<..) Social Security # _

AM

If necessary, best time to call you at home is PM

May we contact you at work? 0 Yes 0 No

AM If yes, work number and best time to call C__)L.- -'-P;.;.;...M

If you are under 18 and it is required, can you furnish a work permit? 0 Yes 0 No

If no, please explain

Have you submitted an application here before? 0 Yes 0 No

If yes, give date(s) _-----'--1_----'-1__

Have you ever been employed here before? ".............................. 0 Yes 0 No

If yes, give dates From _---L.-I_...LI__ To _---l.-I_L.I__

Are you legally eligible for employment in this country?........................................................................................ 0 Yes 0 No

Date available for work _---'1_-----'--1__

Type of employment desired o Full-Time o Part-Time o Temporary o Seasonal o Educational Co-Op

Will you relocate if job requires it? 0 Yes 0 No Will you travel if job requires it? 0 Yes 0 No

Are you able to meet the attendance requirements of the position? 0 Yes 0 No

Will you work overtime if required? DYes ONo

If no, please explain

Have you ever been bonded? 0 Yes 0 No

Have you been convicted of a crime in the last seven (7) years? 0 Yes 0 No

If yes, please explain _ CONVICTION WILL NOT NECESSARILY BE A BAR TO EMPLOYMENT. EACH INSTANCE AND EXPLANATION WILL BE CONSIDERED IN RELATION TO THE POSITION FOR WHICH YOU ARE APPLYING.

Driver's license number if driving is an essential job function State

AN EQUAL OPPORTUNITY EMPLOYER

Employment History &1 illf%!1P'iMji* t@&¥ tiM

Provide the following information for your past and current employers, assignments or volunteer activities, starting with the most recent (use additional sheets if necessary). Explain any gaps in employment in comments section below.

t::Mt-'LOYER

ADDRESS

TELEPHONE

( ) DATES EMPLOYED

FROM TO

SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES

JOB TITLE

IMMEDIATE SUPERVISOR AND TITLE $

HOURLY RATE/SALARY

STARTING

PER

REASON FOR LEAVING

MAY WE CONTACT FOR REFERENCE? DYES DNo D LATER

$

HOURLY RATE/SALARY

FINAL

PER

EMPLOYER

ADDRESS

TELEPHONE

( ) DATES EMPLOYED

FROM TO

SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES

JOB TITLE

IMMEDIATE SUPERVISOR AND TITLE $

HOURLY RATE/SALARY

STARTING

PER

REASON FOR LEAVING

MAY WE CONTACT FOR REFERENCE? DYES DNo DLATER

$

HOURLY RATE/SALARY

FINAL

PER

EMPLOYER

ADDRESS

TELEPHONE

( ) DATES EMPLOYED

FROM TO

SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES

JOB TITLE

IMMEDIATE SUPERVISOR AND TITLE $

HOURLY RATE/SALARY

STARTING

PER

REASON FOR LEAVING

MAY WE CONTACT FOR REFERENCE? [J YES DNO D LATER

$

HOURLY RATE/SALARY

FINAL

PER

EMPLOYER

ADDRESS

TELEPHONE

( ) DATES EMPLOYED

FROM TO

SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES

JOB TITLE

IMMEDIATE SUPERVISOR AND TITLE $

HOURLY RATE/SALARY

STARTING

PER

REASON FOR LEAVING

MAY WE CONTACT FOR REFERENCE? [JYES DNO D LATER

$

HOURLY RATE/SALARY

FINAL

PER

Comments INCLUDING EXPLANATION OF ANY GAPS IN EMPLOYMENT ----~---------------------

Skills and Qualifications - Summarize any special training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.

Employment HistoryProvide the following information for your past and current employers, assignments or volunteer activities, starting with the mostrecent (use additional sheets if necessary). Explain any gaps in employment in comments section below.

t:MPLOYER TELEPHONE DATES EMPLOYED SUMMARIZ-E THE TYPE OF WORK

( ) FROM TO PERFORMED AND JOB RESPONSIBILITIES

ADDRESS

JOB TITLE HOURLY RATE/SALARY

STARTING

IMMEDIATE SUPERVISOR AND TITLE $ PER

REASON FOR LEAVING HOURLY RATE/SALARY

.FINAL

$ PER

MAY WE CONTACT FOR REFERENCE? DYES DNo o LATER

",IIIIPLOYER TELEPHONE DATES EMPLOYED SUMMARIZE THE TYPE OF WORK -( ) FROM TO PERFORMED AND JOB RESPONSIBILITIES

ADDRESS

JOB TITLE HOURLY RATE/SALARY

STARTING

IMMEDIATE SUPERVISOR AND TITLE $ PER

REASON FOR LEAVING HOURLY RATE/SALARY

FINAL

$ PER

MAY WE CONTACT FOR REFERENCE? DYES DNo o LATER

EMPLOYER TELEPHONE DATES EMPLOYED - SUMMAj:lIiE THE TYPE O-F WORK

( ) FROM TO PERFORMED AND JOB RESPONSIBILITIES

ADDRESS

JOB TITLE HOURLY RATE/SALARY

STARTING

IMMEDIATE SUPERVISOR AND TITLE $ PER

REASON FOR LEAVING HOURLY RATE/SALARY

FINAL

$ PER

MAY WE CONTACT FOR REFERENCE? DYES DNO o LATER.,.

EMPLOYER TELEPHONE DATES EMPLOYED .SUMMARIZE THE TYPE OF WORK· .

( ) FROM TO PERFORMED AND JOB RESPONSIBILITIES

ADDRESS

JOB TITLE HOURLY RATE/SALARY

STARTING

IMMEDIATE SUPERVISOR AND TITLE $ PER

REASON FOR LEAVING HOURLY RATE/SALARY

FINAL

$ PER

MAY WE CONTACT FOR REFERENCE? DYES DNo o LATER

Comments INCLUDING EXPLANATION OF ANY GAPS IN EMPLOYMENT --------~-------------------------------------------

Skills and Qualifications - Summarize any special training, skills, licenses and/or certificates that may qualify you as being ableto perform job-related functions in the position for which you are applying.

Educational Background IF JOB·RELATED

A. List last three (3) schools attended, starting with most recent. B. List number of years completed. C. Indicate degree or diplomaearned, if any. D. Grade Point Average or Class Rank. E. Major field of study. F. Minor field of study (if applicable).

B. NUMBER OF YEARS C. DEGREE D. GPAE. MAJOR F. MINORA.SCHOOL

COMPLETED DIPLOMA CLASS RANK

References

List name and telephone number of three business/work references who are not related to you and are not previous supervisors.If not applicable, list three school or personal references who are not related to you.

NAME TELEPHONE YEARS KNOWN

( )

( )

( )

Additional Information

List professional, trade, business, or civic associations and any offices held.EXCLUDE MEMBERSHIPS WHICH WOULD REVEAL SEX, RACE, RELIGION, NATIONAL ORIGIN, AGE, COLOR, DISABILITY OR ANY OTHER SIMILARLY PROTECTED STATUS.

ORGANIZATION OFFICES HELD

List special accomplishments, publications, awards, etc.EXCLUDE INFORMATION WHICH WOULD REVEAL SEX, RACE, RELIGION, NATIONAL ORIGIN, AGE, COLOR, DISABILITY OR OTHER PROTECTED STATUS. _

List any additional information you would like us to consider.

Name(s) & phone #(s) of person(s) to contact in case of emergency -'- _

I understand that if I am employed, any misrepresentation or material omission made by me on this application will be sufficient causefor cancellation of this application or immediate discharge from the employer's service, whenever it is discovered.

I give the employer the right to contact and obtain information from all references, employers, educational institutions and to otherwiseverify the accuracy of the information contained in this application. I hereby release from liability the employer and its representativesfor seeking, gathering and using such information and all other persons, corporations or organizations for furnishing such information.

The employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting orexcusing any applicant from consideration for employment on a basis prohibited by local, state or federal law.

This application is current for only 60 days. At the conclusion of this time, if I have not heard from the employer and still wish to beconsidered for employment, it will be necessary to fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reservesthe same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required bylaw. This application does not constitute an agreement or contract for employment for any specified period or definite duration.I understand that no representative of the employer, other than an authorized officer, has the authority to make any assurances to thecontrary. I further understand that any such assurances must be in writing and signed by an authorized officer.

I understand it is this company's policy not to refuse to hire a qualified individual with a disability because of that person's need for areasonable accommodation as required by the ADA.

I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization.

I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions.

Signature of Applicant _ Date .:»:_-,/c.-_

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Affirmative Action Voluntary InformationCOMPLETION OF INFORMATIONBELOW IS VOLUNTARY

We consider all applicants for positions without regard to race, color, religion, sex, national origin, citizenship, age, mental or physicaldisabilities, veteran/reserve/national guard or any other similarly protected status. We also comply with all applicable laws governingemployment practices and do not discriminate on the basis of any unlawful criteria.

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 recordkeeping, 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 itwill not subject you to any adverse personnel decision or action. Your cooperation is appreciated.

Please be advised that this survey is not a 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. ,

PLEASE PRINT

Position(s) applied for Date _--1./_~/L-_

Referral Sourceo Walk-ino Employeeo Advertisement - Source _

o Government Employment Agencyo Relative

o Private Employment AgencyLl Schoolo Other __ --'-- _

Name of person who referred you IF APPLICABLE _

Applicant Information

Name ~~-------~~-------~~~-----LAST FIRST MIDDLE

Telephone-,-_~ . ...L) _

Address ~~~---------~~--------~~-------~~~---STREET CITY STATE ZIP CODEo Male o Female

Please check one of the following Equal Employment Opportunity Identification Groups:o White (not of Hispanic origin) 0 Black (not of Hispanic origin) 0 Hispanic

---------------------------o American Indian/Alaskan Native 0 Asian/Pacific Islander 0 Multiracial (having parents of different races)THIS IDENTIFICATIONGROUP IS RECOGNIZEDONLY INTHE STATEOF MICHIGAN.

For Administrative Use Only

Position(s) applied for o Available o Not Available

Other positions considered for _

Hired 0 Yes 0 No

Position hired for _ Date of hire __ -'--/__ -'--/__

From the EEO job classifications listed below, which one best describes the position filled?o Officials and Managers 0 Sales Workerso Professionals 0 Office and Clerical Workerso Technicians 0 Craft Workers (skilled)

o Operatives (semi-skilled)o Laborers (unskilled)o Service Workers

Notes _

Completed by _ Date __ 1"---_-"-1__

Creative Printing, La Crosse, KS

RUSH COUNTY MEMO'RIAL HOSPITAL AND LONG TERM CARE UNIT801 LOCUST STREET, P.O. BOX 520

LA CROSSE, KANSAS 67548-0520TELEPHONE 785-222-2545- FAX 785-229-2868

CONSENT TO REQUEST INFORMATION

I have made application for employment (or am employed) at Rush County Memorial Hospital and LongTerm Care Unit. -

I know that Rush County Memorial Hospital and Long Term Care Unit is required by regulations found in43 CFR 483.13 (c) (1) (ii) not to employ any individual who:

(A) Has been found guilty of abusing, neglecting, or mistreating individuals by a courtof law: or

(8) Has had a finding entered into the State Nurse Aide Registry concerning abuse, neglect,mistreatment of resident or misappropriation of a resident's property involving theemployee or applicant for employment.

I know that Rush County Memorial Hospital and Long Term Care Unit is required by Federal and Statelaws to make an inquiry of the appropriate public records and licensing registry. Inquiries will be made ofvarious courts of law and various law enforcement agencies. These inquiries are to determine if thereare any records concerning me, of a conviction by a court of law of abuse, neglect, or mistreatment of anindividual or a finding entered into a licensing registry concerning abuse, neglect, or mistreatment ofresident or misappropriation of his/her property.

I am aware that if such information is found, any offer of employment will be withdrawn, or if I am anemployee and such information is found, my employment will be immediately terminated.

I am also aware that if at any time during my employment by Rush County Memorial Hospital and LongTerm Care Unit, that the Rush County Memorial Hospital and Long Term Care Unit acquires knowledgeof my conviction of abuse, neglect, or mistreatment of an individual or the entry of a finding in a licensingagency concerning abuse, neglect, or mistreatment of resident or the misappropriation of his/her prop-erty, my employment by the Rush County Memorial Hospital and Long Term 'Care Unit will be terminatedimmediately. I also consent to take a blood test at the request of my supervisor or their supervisor for thedetermination of use of illegal substances, prior to employment or anytime after employment.

I hereby give my consent to the Rush County Memorial Hospital and Long Term Care Unit to make theinquiries described above. I also acknowledge that I am aware of what may be the result of such recordsas is described above.

(Signature) (Date)

L.--------- - --- ~-- -------- -----------