PERSONAL
***Name as it appears on Social Security Card
Last Name:  Middle: 
First Name:  Social Security Number: 
Address:  City: 
State:  Zip: 
Primary Phone:  Type: Secondary Phone:  Type:
Email Address:     
How were you referred to the Medical Center?
Agency Newspaper Career Fair/Convention College Walk-in Internet Other
If newspaper please name: 
  HMC associate name: 
Have you ever been convicted for a violation of any federal, state, county or municipal law,  regulation, or ordinance. (Do not include traffic violations)
Yes No
If yes please explain:
A conviction record will not necessarily be a bar to employment,  and factors such as age and time of the offense, the seriousness and nature of the  violation, and the applicant's rehabilitation will be considered in the hiring decision.
CITIZENSHIP
Are you legally eligible for employment in the United States?
   Yes No
If yes, and you are not a U.S. Citizen, please provide the number of your Resident Alien or World Authorization Card.
Form 1-15: Form 1-94: Class:
EDUCATION
School Name of School Location(City and State) Years
Completed 		Graduate Degree Year
Graduated
High School
College
Graduate Program
Technical or Professional
School of Nursing
Other
MILITARY DATA
From (Month/Year): To (Month/Year):
Branch: Reserve of National
Guard Status: 		Active Inactive Training Obligation
Rank at Discharge:  
Job Duties Including Special Training:
JOB INFORMATION
Position(s) applying for: 1. 2.
Facility Hays Medical Center Pawnee Valley Hospital Both
Employment Desired: FT PT PRN
Shifts available: Days Evenings Nights Weekends Only Other
If other please specify:
Days available: Sun Mon Tue Wed Thu Fri Sat
Date available to work:
EXPERIENCE /SKILLS CHECKLIST
Work Skills
Word Processing
PBX Switchboard Operator
Transcription 		Work Skills
Medical Terminology
Medical Insurance Billing
Filing Skills
Medical Records Coding
Accounts Payable
Computer Skills
Microsoft Office
Windows
Data Entry
Data Programming
Personal Computer

OR/Surgery
Oncology
Skilled Nursing
Rehabilitation
OB - Women's Center

Medical/Surgical
Critical Care : ICU-CPCU
Orthopedic
Cath Lab
Radiology Specialty

Telemetry
Obstetrics
Hospice
Clinic
EMPLOYMENT HISTORY
List names of employers in consecutive order with present or last employer listed first.   Account for all periods of time including military service and any period of unemployment.   If self-employed, give firm name and supply business references.  PLEASE GIVE MONTH AND YEAR.
Reference 1
Company Name Title
Phone Salary
Address City
State    
Dates of Employment Supervisor
Description of Duties:
Reason for Leaving:

Reference 2

Company Name Title
Phone Salary
Address City
State    
Dates of Employment Supervisor
Description of Duties:
Reason for Leaving:

Reference 3

Company Name Title
Phone Salary
Address City
State    
Dates of Employment Supervisor
Description of Duties:
Reason for Leaving:
May we contact your present employer?
   Yes No
Were you previously employed by Hays Medical Center, Hays Pathology Laboratories or Central Plains Laboratories?
   Yes No
If Yes, when and position held.
  
Under what name if different than listed above:
  
Are you related to any present employee?
   Yes No
If yes, whom and relationship.
  
Are you 18 years of age or older?
   Yes No

The Age Discrimination in Employment Act prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age.  The Kansas Act Against Discrimination on the basis of age with respect to individuals who are at least 18 years of age.
PROFESSIONAL LICENSES AND CERTIFICATES
Type State Issued Expiration Date Number
Is your current license under suspension?
   Yes No
If yes, explain:
  
Has any action ever been taken against your (current or past) license in any state?
   Yes No
If yes, explain:
  
Are you currently or have you ever been included on the Federal Medicare Exclusion List?
   Yes No
If yes, explain:
  
REFERENCES
Please list three references.  Please do not include relatives or former employers.
Name Email Address Phone
If employed by Hays Medical Center, do you plan to work at another job in addition to your work at Hays Medical Center?    Yes No
If yes, where?
What hours and days?
Are you able to perform, with or without an accommodation, the essential tasks of the job for which you are applying without posing a direct threat to the health or safety of yourself or others? (Please review job description before answering, available in Human Resources) Yes No
READ CAREFULLY BEFORE SIGNING
I hereby authorize Hays Medical Center to solicit all information desired with this application including matters of opinion, character, ability, reputation, past conduct and also authorize and request each person or firm referred to in this application to give such information.   In marking the "I Agree" check box below for employment, I clearly understand and agree; (1) that all the statements are true to the best of my knowledge; (2) that no attempt has been made to conceal or withhold pertinent information; (3) any falsification, misrepresentation, omission or additional (not requested) unnecessary information on my part is cause for refusal to employ me or for termination if I am employed;   (4) that my previous and present employers may be asked for information relating to my prior employment or character and I authorize Hays Medical Center to make any investigation, and my previous and present employers to release information they may deem advisable with no liability arising therefore; (5) if hired, I will abide by all Medical Center rules and regulations and policies; (6) my employment and compensation can be terminated,   with or without cause, and with or without notice, at any time; at the option of either the Medical Center or myself; and (7) I understand that no representative of the Medical Center, other than the Chief Executive Officer of the Medical Center, has any authority to enter into any agreement for employment for any specified period of time, or make any agreement contrary to the foregoing.
I Agree I Disagree


 

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