Name*
Are You at Least 18 Years Old?*
Social Security Number without dashes or spaces (secure)*
Phone*
Present Address*
Present City*
Present State*
Present Zip Code*
Email*
Previous Address*
Previous City*
Previous State*
Previous Zip Code*
Position You Are Applying For*
Are you currently credentialed for the position for which you are applying?*
Type of Position*
Shift*
Salary Requirement*
Are You Willing To Travel?*
Are You Willing To Relocate*
Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?*
If overtime work is required periodically, does this pose a problem for you?*
Date Available For Work*
Are You Legally Authorized to Work in the U.S.?*
Have you ever worked for Castro County Healthcare?*
If yes, what year did you leave?*
Are you related to another facility employee?*
How did you learn about this position?*
Are you able to perform the essential, job related functions of the position for which you are applying with or without reasonable accommodations?*
Describe any accommodations necessary:*
Have you been convicted of a crime and/or released from confinement following a conviction for any criminal offense?*
Arrests or charges that have been expunged need not be disclosed.*
If yes, give date, place and nature of each such conviction:*
Are you presently charged with any violation of the law?*
Are you currently excluded from participation in any federally funded healthcare program - including Medicare and Medicaid - and are you aware of any potential exclusion from a federally funded health program?*
High School Name
High School City
High School State
Check Last Year Attended in School
Graduated/GED?
High School Degree/Date Graduated
College Name
College City
College State
Check Last Year Attended in College
Graduated?
College Degree/Date Graduated:
College Degree/Date Graduated
Graduate School Name
Graduate School City
Graduate School State
Check Last Year Attended in Graduate School
Graduate Degree/Date Graduated
List any professional licenses, registration or certification you possess*
Clerical or other skills applicable to the position for which you are applying
Provide information regarding previous employment beginning with most recent employer - Job Title*
From
To
Supervisor Name
Salary
Employer's Name*
Employers Phone Number
Employers Address
Hours Worked a Week
Name Employed Under
Job Duties
Reason for Leaving
May we contact your current employer*
Job Title
Type
Employers Name
Employer's Phone Number
Employer's Address
May we Contact your current employer?
References - Name and Relationship*
Position
Address
Phone Number
Years Known
Name and Relationship
Attach Resume*