ESMC Online Employment Application 

All information is submitted at your own risk. ESMC is not responsible for, and makes no representations regarding, the security of information submitted on-line. ESMC is not responsible if this information is accessed by an outside source. For this reason we do not ask for your Social Security # or Driver License #. 

Personal Information

Full Name:

Date (mm/dd/yy):

Present Address:

Phone # (###-###-####): ext.

Email:


Employment Desired

Type of work desired:
1st choice:
2nd choice:
3rd choice:

Will you accept employment of (please check one):

Full Time Part Time Temporary


Education

Indicate the highest grade of education completed:

8 9 10 11 12 13 14 15 16

Name of High School:

Did you Graduate? Yes No

Location:

Name of College:

Did you Graduate? Yes No

Location:

Name of Vocational or Business School:

Did you Graduate? Yes No

Location:

Professional Education (name):

Did you Graduate? Yes No

Location:

Lab or XRay Training:

Did you Graduate? Yes No

Location:


Employment Record

Current Employer:

Dates employed:

Starting - Ending Salary (Annual):

Address:

Supervisor:

Phone # (###-###-####): ext.

Position and Duties:


Former Employer:

Dates employed:

Starting - Ending Salary (Annual):

Address:

Supervisor:

Phone # (###-###-####): ext.

Position and Duties:


Former Employer:

Dates employed:

Starting - Ending Salary (Annual):

Address:

Supervisor:

Phone # (###-###-####): ext.

Position and Duties:


List ESMC employees related to you and how they are related below:


If your former employment references or education are under a name other than indicated at top of application, please indicate in box below.



Employment Understanding 

This institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, Vietnam era veteran status, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.

I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I consent to take the physical examination, and such future physical examination as may be required by this institution at such times and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physical examination which relates to the essential duties I would be required to perform. 

I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.

If employed, I will be required to complete an Employment Verification Form (I-9), and within three days show satisfactory evidence of identity and eligibility for employment.

I further understand and agree that by clicking the submit button I am agreeing to the terms of this Employment Understanding, and I am releasing Excelsior Springs Medical Center from any liability or claim of any kind relating to my on-line submission of this application or to the use, theft or access of the information contained herein by any person or entity who may access the information. 

After you click the submit button, you will be taken to a confirmation page showing you the info you filled in. You may close this window at this time and be returned to the ESMC website.