This application is for:

(chose one)   Hutchinson Hospital Horizons Mental Health Center Dillon Living Center Hospice of Reno County Prairie Star Health-E-Quip

As an equal opportunity employer, this firm will not discriminate unlawfully against any employee or applicant for employment because of race, color, religion, sex, age, national origin, ancestry, disability, or other legally protected reason. An applicant requiring reasonable accommodation to the application and or interview process should notify a representative of the Human Resources Department.

Personal Information (* required)

Applicant Name *

Last: First: Middle:

* Soc. Sec. Number: *

Address

Street: * City: * State: * Zip:

Contact Information

Telephone:      Email Address:

Are you under age?    Yes No

If Yes, can you furnish a work permit (SS Card, Birth Certificate) if required?    Yes No

Have you had a misdemeanor or felony conviction?    Yes No *

If Yes, please explain the nature of the conviction(s), when, and where it occurred. 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 violations, and the applicant's rehabilitation will be considered in the hiring decision.

Have you been sanctioned for Medicare or Medicaid Fraud or Abuse?     Yes No * If Yes, please explain:

Employment Information

Position(s) applied for or type of work desired: *

Employment Type Desired:   Full Time Part Time Temporary Call-in *

Shift Preferred:   Day Evening Night Weekends Only *

Are you able to work weekends and holidays?  Yes No *

Can you work overtime when required?     Yes No *

Are you able to meet the attendance requirements?    Yes No *

Have you worked for this firm before?    Yes No *

If yes, under what name?

Are you related to or living in the same household with any person(s) currently employed by this firm?    Yes No *

If yes, please state person(s) name(s):

Are you presently employed?    Yes No *

If so, may we inquire of your present employer?    Yes No *

Education

High School

School Name: Location: Years Completed: Course of Study: Degree Earned:

College

School Name: Location: Years Completed: Course of Study: Degree Earned:

Technical/Other

School Name: Location: Years Completed: Course of Study: Degree Earned:

Registered, Licensed, and Certified Nursing Applicants
Complete This Section

RN   BSN   MS   Diploma    Associate Degree Kansas License?    Yes No

Kansas License/Certification Number?

Expiration Date?

Other Medical Registered, Licensed or Certified Applicants
Complete This Section

License, Registration / Certification Number?

Expiration Date?

Are you currently licensed, registered or certified in Kansas?    Yes No If Not, have you applied?    Yes No License, Registration or Certification Number?

Expiration Date?

Former Employers, List Last Four Employers; Start with Last Employer First

Mo/Yr	Name and Address of Employer	Salary	Position	Reason for Leaving
From To
From To
From To
From To

Personal References *
(You have known 2 Years or More, Please Provide 2)

Name	Address	Phone #	Years Known

Other Skills and Qualifications
Summarize any job-related training, skills, certificates, and/or other qualifications

I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions and all other person or organizations for providing such information. In signing this application for employment, I clearly understand and agree: that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered. If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either the employer or I can terminate the relationship at will, with or without cause, at any time, with or without notice. I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment. I will consent to any and all examinations required by the firm, including drug and alcohol testing. I authorize this firm to make any lawful investigations, including criminal background checking. If hired, I will abide by all Company rules, regulations and Code of Conduct and Compliance. Upon my termination, the firm may release reference information on my work. By clicking the button below, I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.

Signature

Full Name: *

Date: *