APPLICATION FOR EMPLOYMENT
Excelsior Springs Hospital is an Equal Opportunity Employer
Application Date: 5/17/2012 7:32:55 PM  Date Available:  
PERSONAL INFORMATION
Name:
Street/P.O.Box:   
City:   State:   Zip: 
Home Phone: Cell Phone: eMail Address:
EMPLOYMENT DESIRED
Type of Work Desired Shift Salary
1st Choice: 
2nd Choice:
3rd Choice:
Have you applied to this company before? 
Will you accept employment of: Full Time   Part Time  Temporary
Are you 18 yeas of age or older? 
How did you learn of this opening?
EDUCATION
  Name of School Location
(City/State)
Courses
Taken
Completed Type of Degree or
Certificate Received
HighSchool
College
Vocation or Professional
Professional Education
Extracurricular activities while in school:
Member of Professional Organizations:
PROFESSIONAL LICENSES AND/OR CERTIFICATIONS
Type Organization or State Issued Date Issued Number Verified
EMPLOYMENT RECORD (list last or present position first)
Present or Former Employers Dates
Employed
Salary
Range
Position and Duties
Reasons for Leaving
Name:
Address:
City/State/Zip:
Supervisor:
Phone:
From:

To:
Starting:

Ending:

Skills learned while in this position:
Name:
Address:
City/State/Zip:
Supervisor:
Phone:
From:

To:
Starting:

Ending:

Skills learned while in this position:
Name:
Address:
City/State/Zip:
Supervisor:
Phone:
From:

To:
Starting:

Ending:

Skills learned while in this position:
List Employees related to you. Relationship (ie. Spouse, Brother, Son, etc.)
If your former employment references, education or military service are under a name other than indicated on this application, please indicate here:
Have you ever been convicted of a crime?
If yes, for what, when and where?
Conviction of a criminal offense will not necessarily preclude your employment.
Use this space to give us further information which will assist us in placing you, including at least two professional references (with addresses and phone numbers) not related to you, whom you have known at least one year.
EMPLOYMENT UNDERSTANDING (Please Read and Initial Below)

This institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, Vietnam era 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 liability or responsibility all persons, companies or corporations supplying such information.  I consent to take the physical examination, and such future physical examinations as may be required by this institution at such times and places as the institution shall designate, which will include drug testing.

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

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

By entering my initials here and dating here I agree that all information given is true and accurate and freely offer this employment application for consideration.

AVAILABILITY RECORD

Primary position desired:
Will you accept another position?   If yes, what?
Are you available to work: Weekends?   Holidays?   Rotating Shifts?
Do you limit your annual earnings due to Social Security or other reasons?
If yes, please state what is the maximum amount you wish to earn?

I understand that emergency conditions may require me to temporarily work shifts other than the one for which I am applying and agree to such scheduling change as directed by my department head or administrator of this institution. 
By entering my initials here and dating here I agree to the above paragraph.

 

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