PERSONAL INFORMATION

Name  -  Last                                              First                           Middle Initial        Social Security No.                       Today’s Date

Address— Street                                                                                                                                                 Home Telephone Number

City                                                       State                 Zip                                                                             Cell or Alternate Phone Number

Position Desired                                                                      Training for This Position     (Formal education shown below.)

Other specialized Training or Experience (Not Necessarily for this Job)

Have you ever been convicted of a felony?   If yes, please describe.

Professional License/ Registration NO.

Please attach a copy                                                                            Type                                                                            State

Hobbies or Special Interests:

In Case of an Emergency, Please Notify

Name                                                                                          Relationship                           Address                                    Telephone #

Name, Address & Phone #

EDUCATION

Name and Location of

Schools or Colleges

FORMER EMPLOYERS AND EXPERIENCE (REFERENCES)

 

Major Subject (s)

Did You

Graduate?

Type of

Degree/Certificate

Date of Graduation

College/Vocational Only

PERSONAL REFERENCES (NOT RELATIVES)

Name                                                                        Address                                                               Phone                                    Relationship

EMPLOYMENT UNDERSTANDING (PLEASE READ AND SIGN)

Please print the form and mail to :  Trego County Lemke Memorial Hospital, 320 N. 13th, WaKeeney, Ks.    67672

For more information, email us at tclmh.org or call 785-743-2182.

_______________________________________________________________

Signed                                                                                                                                                   Date

 

Experience

Period

From

To

Cash

Salary

Other

Compensation

This institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, or on the basis of age or physical or mental disability unrelated to the ability to perform the work required.  No questions or 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 of such information.  I consent to take the physical examination, drug screen and such future physical examinations and drug screens as may be required by this institution at such times and places as this institution shall designate.  I understand that employment in the position offered is contingent upon successful completion of a physical examination, drug screen and criminal background check.

 

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 within three days and show satisfactory evidence of identity and eligibility for employment.