Application For Employment

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status.

How Did You Learn About Us?





Last Name
First Name
Middle Name
Address
City
State
Zip Code
Telephone Number(s)
Social Security Number
Best time to contact you at home is
If you are under 18 years of age can you provide required proof of your eligibility to work?
Have you ever filed an application with us before?

If yes, give date:
Have you ever been employed with us before?

If yes, give date:
Do any of your friends or relatives, other than spouses, work here?
Are you currently employed?
May we contact your present employer?
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status
Proof of citizenship or immigration status will be required upon employment.
Date available for work
What is your desired salary range?
Are you available to work

Full-Time (please indicate 1 2 3 shift)

Part-Time (please indicate Mornings Afternoons Evenings)

Temporary (please indicate dates available)

Are you currently on "lay-off" status and subject to recall?
Can you travel if a job requires it?

WE ARE AN EQUAL OPPORTUNITY EMPOYER

Education

Elementary School

Name and Address of School
Course of Study
Years Completed
Diploma/Degree

High School

Name and Address of School
Course of Study
Years Completed
Diploma/Degree

Undergraduate College

Name and Address of School
Course of Study
Years Completed
Diploma/Degree

Graduate College

Name and Address of School
Course of Study
Years Completed
Diploma/Degree

Other

Name
Name and Address of School
Course of Study
Years Completed
Diploma/Degree
Describe any specialized training, apprenticeship, skills and extra-curricular activities.
Describe any job-related training received in the United States.

Employment Experiences

Start with your present or last job. include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

Employer
Address
Telephone Number(s)
Job Title
Supervisor
Reason for Leaving
Date Employed
Hourly Rate/Salary (starting/final)
Work Performed
Employer
Address
Telephone Number(s)
Job Title
Supervisor
Reason for Leaving
Date Employed
Hourly Rate/Salary (starting/final)
Work Performed
Employer
Address
Telephone Number(s)
Job Title
Supervisor
Reason for Leaving
Date Employed
Hourly Rate/Salary (starting/final)
Work Performed
Employer
Address
Telephone Number(s)
Job Title
Supervisor
Reason for Leaving
Date Employed
Hourly Rate/Salary (starting/final)
Work Performed
List professional, trade, business or civic activities and offices held.
You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status

Additional Information

Summarize special job-related skills and qualifications acquired from employment or other experience.
Specialized Skills Check Skills/Equipment Operated
Terminl
PC/MAC
Typewriter
WPM
Spreadsheet
Word Processing

Production/Mobile Machinery (list)

Other (list)

State any additional information you feel may be helpful to us in considering your application

Note to Applicants:DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.
Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? A review of activities involved in such a job or occupation has been given.

References

Name
Address
Telephone Number
Name
Address
Telephone Number
Name
Address
Telephone Number

Applicant's Statement

I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which meane that the Employee may resign at any time and the Employer may discharge Employee at any time with or with out cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Check box for agree or disagree and date.

Post Offer Authorization for Release of Information

I hereby request and authorize the Kansas Bureau of Investigation to furnish the above named company with criminal history information.

I voluntarily waive all right of resource and release Sumner Regional Medical Center from liability for compliance with this authorization.

Last name
First name
Middle name
Maiden name
Address
City
State
Zip Code
Sex
Race
**Birthdate
Social Security Number
Place of Birth
Other Alias Name
Other Alias Name
Other Alias Name

**Not required unless conditional offer of employment is made.

Check box for agree or disagree.

Applicant Release Authorization to Release Information

(To be used regarding applicants for pre-employment references)

I authorize Sumner Regional Medical Center to contact any company, institution, or individual it deems appropriate to investigate my employment history, job performance, background, qualifications, driving record, and other relevant information, if job related. I give my full consent for all contacted persons including former employers to provide the information concerning this application. I waive my right to bring any cause of action against these individuals for any and all liability for damages arising from furnishing the requested information to Sumner Regional Medical Center.

Check box for agree or disagree.