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equal opportunity employer


Date: 05/19/2013
1) Position Applying For and Availability:
1st Choice:
2nd Choice:
full time part time PRN any
Are you available to work: days evenings nights any weekends holidays rotating shifts Please indicate any days of the week or times during a particular day you are not available for work.
Date available for employment	Minimum salary desired $
I understand that assignments and scheduling may vary to meet the needs of the hospital and I may be required to work other areas or shifts.

2) Your Information

Last Name	First Name	Middle Name
Present Address	City	State	Zip
Telephone Number	Alternate Number	E-Mail Address
SSN - -
Are you legally eligible to work for employment in the United States?		Yes No
Have you ever applied for work at Ste. Genevieve County Memorial Hospital System before?		Yes No
Have you ever worked for Ste. Genevieve County Memorial Hospital System before?		Yes No
If yes, when?		What name were you employed under?
Do you have a reliable means of transportation to get to work?		Yes No
Person to be notified in case of emergency: Name: Phone:

3) Education

Education Level	School Address	Degree/Diploma	Major Field of Study	Years Completed
High School
Vocational/ Technical Training
College(s) Attended
What profession/skill are you licensed/registered for?
Date first issued? License No. State

4) Experience
Please complete the following section even if a resume is enclosed. List all employers starting with most recent. List all employers for the past 10 years or the last four employers, whichever covers the longest period. You may list more employers on a separate sheet of paper if you desire. If previously employed under another or maiden name, please indicate so.

Company Name
Address	City State Zipcode
Dates of Employment	to Name appearing in former employer's records
Last position held	Wage $ per
Describe job duties
Specific reason for leaving		Voluntary Involuntary
Name of last supervisor	Ph. #	May be contacted for references*: Yes No

Company Name
Address	City State Zipcode
Dates of Employment	to Name appearing in former employer's records
Last position held	Wage $ per
Describe job duties
Specific reason for leaving		Voluntary Involuntary
Name of last supervisor	Ph. #	May be contacted for references*: Yes No

Company Name
Address	City State Zipcode
Dates of Employment	to Name appearing in former employer's records
Last position held	Wage $ per
Describe job duties
Specific reason for leaving		Voluntary Involuntary
Name of last supervisor	Ph. #	May be contacted for references*: Yes No

Company Name
Address	City State Zipcode
Dates of Employment	to Name appearing in former employer's records
Last position held	Wage $ per
Describe job duties
Specific reason for leaving		Voluntary Involuntary
Name of last supervisor	Ph. #	May be contacted for references*: Yes No

5) References
(Please exclude former employers and persons related to you)

Name & Occupation	Address	Email	Phone

6) Miscellaneous

Please list any friends or relatives working for Ste. Genevieve County Memorial Hospital.

Have you ever been convicted or plead guilty to a misdemeanor or felony charge (other than minor traffic offenses) including any suspended imposition of sentence, any suspended execution of sentence or any period of probation or parole? Yes No
If yes, please explain
I understand that a prior conviction may not necessarily disqualify me for employment but will be a factor which may be considered in the hiring process. Yes No
The hospital conducts criminal background checks on all new employees in accordance with Missouri and Federal law.
Occasionally the form of an application blank makes it difficult for an individual to adequately summarize their complete background. To assist us in finding the proper position for you in our hospital, use the space below to summarize any additional information necessary to describe your full qualifications.

What prompted your application?

Own Accord Employee Internet
Newspaper Employment Service
Other

APPLICANT AUTHORIZATION AND CONSENT
FOR RELEASE AND DISCLOSURE OF INFORMATION

I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge. I understand that if employed, falsified statements, misleading statements, or omissions on this application shall be considered sufficient cause for dismissal. You are hereby authorized to conduct an investigation of any information provided on this application.

I understand that Ste. Genevieve County Memorial Hospital (SGCMH) participates in E-Verify and will provide the Social Security Administration (along with the Department of Homeland Security, if necessary) information from my Form I-9 to confirm my work authorization. All new employees are required to undergo blood and/or urinalysis screening for drug use as part of their pre-employment health screening. If I am accepted for employment, I agree to take a drug and/or alcohol test(s) when requested by SGCMH. I understand that taking such tests is a condition of my employment.

Also, as a requirement of the employment application process, I consent to the release of my criminal records to my employer. My prospective employer will consider material contained in my criminal history records solely for the purposes of determining my suitability for the position(s) for which I applied. I do not authorize release of this information for any purposes beyond this employment decision. I understand this application does not create an employment relationship or a contract of employment with Ste. Genevieve County Memorial Hospital.

Should I become employed as a result of my application inquiry, my employment will be “at will” and SGCMH will have the right to terminate my employment without notice or cause. This application is active for only 90 days. At the conclusion of this time, if I have not heard from SGCMH and still wish to be considered for employment, it will be necessary to fill out a new application.

I agree to these terms: Yes No

Digital Signature