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Ste. Genevieve County Memorial Hospital
Online Employment Application

when filling in the application, please press the tab key to advance to the next field

1) Personal

Last Name

First Name

Middle Name

Present Address

City

State

Zip

Telephone Number

Alternate Number

E-Mail Address

Position(s) Applying for:

Other Areas of Interest

Are you employed Now? Yes No
If YES, Where?

2) Availability

3) Education

Highest Education Level Achieved	Course of Study
Did you Graduate? Yes No	List Diploma or Degree
Other Business College or Special Courses
Computer Skills? Yes No	Software Knowledge (list)
Knowledge of Medical Terminology? Yes No

4) Relevant Experience

Last or Current Position	Company
Supervisor	Phone
Last Salary Paid	Hours per week
Date From	Date To
Description of Duties
Reason for Leaving

Position	Company
Supervisor	Phone
Last Salary Paid	Hours per week
Date From	Date To

Description of Duties

Reason for Leaving

Position	Company
Supervisor	Phone
Last Salary Paid	Hours per week
Date From	Date To
Description of Duties
Reason for Leaving

5) References

Name	Position	Phone	Address

6) Job Related Skills, Membership in Professional Organizations, Other Comments

7) General Information

A criminal background check may be required. Have you ever been convicted of a criminal offense other than a juvenile conviction which has been expunged? (Conviction of a crime will not necessarily bar you from employment.)
YesNo	Please describe in full:
In the past three (3) years, have you ever knowingly used any controlled substances, including narcotics, amphetamines, barbiturates, other than those prescribed to you by a physician?
YesNo	Please describe in full:
As a condition of employment, you will be required to submit to a drug screening. Do you object to this? YesNo
Can you safely perform all of the functions of the particular job(s) for which you are applying, with or without reasonable accommodation, including its work attendance requirements? YesNo

8) Smoking and Drug Free Workplace

Our policy is to promote and provide a safe and healthy environment for our patients, residents, employees, physicians, students, volunteers and visitors. Therefore, we discourage the use of all tobacco products and regulate smoking within our facility. Additionally, we prohibit the use of illegal drugs.

If employed, will you uphold the hospital smoking policy? YesNo

If employed, will you uphold the hospital drug free workplace policy?
YesNo

9) Other

Who referred you
to this facility?

Employee
Friend or Relative
Advertisement, Newspaper or Journal
Name of publication
School Counselor
Walk In
Previously employed by SGCMH
Date Employed:
Website

APPLICANT AUTHORIZATION AND CONSENT
FOR RELEASE AND DISCLOSURE OF INFORMATION

I understand that employment is conditioned on the results of a drug test and criminal background check conducted by the Hospital. A random drug test may be required by this institution at such times and places as the institution shall designate.

I further understand that my employment and compensation can be terminated at any time at the option of the Hospital or myself. Upon termination, I authorize the release of reference information on my work.

I further understand that this institution follows the "fair employment practice code" and there is no discrimination in the hiring of individuals based on sex, race, religion, age, or handicap unrelated to ability to perform the work required.

I authorize STE. GENEVIEVE COUNTY MEMORIAL HOSPITAL and Pre-Employment Screening, Inc. a consumer reporting agency, to retrieve information from all previous employers work history, education institutions, government agencies, law enforcement agencies at the federal, state or county level, agencies or individuals, relating to my past activities, to supply information concerning my background, and release the same from liability resulting in providing such information. The information received may include, but not limited to previous employment, education, motor vehicle, social security, credit and a criminal background check. I understand that the consumer report may be prepared summarizing this information.

I authorize Pre-Employment Screenings, Inc. of St. Louis, Missouri (hereinafter referred to as "PES") and any of its agents/designated representatives, to disclose orally, electronically, and in writing the results of its verification process and/or interview to the designated authorized representatives of the Company.

I do hereby forever discharge the Company, its agents, PES, and its associates to the full extent permitted by the law from damage, losses, liabilities, costs and expenses, or other charge of complaint filed with any agency arising from the retrieving and reporting of information. According to the Federal Fair Credit Reporting Act, I am entitled to know if adverse action is based on information obtained by the Company and to receive, orally, written or electronically, a copy of the consumer report and a description of the rights of a consumer.

I hereby certify that all of the statements and answers set forth on the application form and/or my resume are true and complete to the best of my knowledge, and I understand that if subsequent to employment any such statements and/or answers are found false or that information has been omitted, such false statements or omissions will be just cause for the termination of my employment.

I agree to these terms: Yes No