* All fields marked with a red asterisk are required. ***Name as it appears on Social Security Card
Last Name :	*	Middle Name :	*
First Name :	*	Social Security Number:	*
Address:	*	City:	*
State:	*	Zip:	*
Primary Phone:	Type: Cell Home Work *	Secondary Phone:	Type: Cell Home Work
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, other than traffic violations?
* Yes No
If yes please explain, including a description, date and location of each conviction.
A conviction record will not necessarily be a bar to employment. 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. However, failure to disclose information will be sufficient cause to eliminate applicant from further consideration for employment or may result in immediate termination upon discovery.

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:

School	Name of School	Location(City and State)	Years Completed	Graduate	Degree
High School
College
Graduate Program
Technical or Professional
School of Nursing
Other

From (Month/Year):		To (Month/Year):
Branch:		Reserve of National Guard Status:	Active Inactive Training Obligation
Rank at Discharge:
Job Duties Including Special Training:

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:

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

Provide 7 years of employment history, including any periods of military service or unemployment, starting with your current employment status and working backwards in time. If you were self-employed, provide the name of your business and one business reference. Please include month and year for each entry. Incomplete information may disqualify you from further consideration Incomplete information may disqualify you from further consideration. Current or most recent employer Company Name Title Phone Salary Address City State     Dates of Employment Supervisor's Name and Title Description of Duties: Reason for Leaving: Employer 2 Company Name Title Phone Salary Address City State     Dates of Employment Supervisor's Name and Title Description of Duties: Reason for Leaving: Employer 3 Company Name Title Phone Salary Address City State     Dates of Employment Supervisor's Name and Title 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.

Type	State	Date 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:

Please list three references. Please do not include relatives or former employers.
Name	Email Address	Phone
1. *	*	*
2. *	*	*
3. *	*	*
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

*** Resumes will only be accepted in a PDF format. Any other file format cannot be uploaded.
(Free PDF Conversion tools available on the internet.)

In submitting this application and marking the "I Agree" check box below, I understand and agree that all the statements in this application are true, that I have not made any attempt to conceal or misrepresent pertinent information, and that any falsification, misrepresentation, or omission of information requested is cause for refusal to hire me or termination if I am employed. I hereby authorize the Medical Center to verify the facts stated on any application or resume I submit to the Medical Center. I further authorize the Medical Center to investigate my employment and educational history, criminal record (including a criminal background check with the Kansas Bureau of Investigation), driving record, character, general reputation, and personal characteristics. I understand this investigation may include a request for information from my present and previous employers relating to my employment or character, and I authorize those employers to release information they may deem advisable with no liability arising therefore. I understand that the Medical Center may decline to hire me or may terminate my employment based on any information discovered in any such investigation, including information in my criminal record. I further agree that if I am hired, (1) I will abide by all Medical Center rules, regulations, and policies; (2) I will be an employee-at-will and my employment may be terminated by me or the Medical Center, with or without cause, for any reason, and with or without notice, at any time; and (3) no representative of the Medical Center other than the Chief Executive Officer has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing. * I Agree I Disagree