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Home
>
Career Opportunities
> Online Application Form
Online Application Form
* = Required Fields
Secure Application for Employment
It is the policy of this facility to provide equal opportunity to persons regardless of race, religion, age, gender, disability or any other classification in accordance with federal, state and local statutes, regulations and ordinances.
*
First Name:
*
Last Name:
*
Middle Initial:
*
Social Security #:
*
Present Address:
*
Present City:
*
Present State:
*
Present ZIP:
Previous Address:
Previous City:
Previous State:
Previous ZIP:
*
Home And Cell Phone:
E-Mail Address:
*
Date Available For Work
*
Salary Requirements:
*
Position
Applied For #1
Position
Applied For #2
Position
Applied For #3
*
Type of Position
Per Diem
Full Time
Part Time
Pool
PRN
Temporary
*
Shift
Day
Night
Evening
Weekend
Rotation
*
How did you learn about this position?
State Employment Commission
Internet
Agency
Ad
Job Listing
School
Current Employee
Job Line
LinkedIn
Other
*
Are you at least 18 year of age?
Yes
No
*
Are You Legally Authorized to Work in the U.S.?
Yes
No
*
Are you willing to travel?
Yes
No
*
Are you willing to Relocate?
Yes
No
*
Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?
Yes
No
*
If overtime work is required periodically, does this pose a problem for you?
Yes
No
*
Have you ever worked in this or any other facility?
Yes
No
If yes, what facility?
*
Are you related to another facility employee?
Yes
No
If yes, who?
*
Are you able to perform the essential, job related functions of the position for which you are applying with or without reasonable accommodations?
Yes
No
Describe any accommodations necessary:
*
Have you been convicted of a crime and/or released from confinement following a conviction for any criminal offense? Arrests or charges that have been expunged need not be disclosed.
Yes
No
If yes, give date, place and nature of each such conviction.
*
Are you presently charged with any violation of the law?
Yes
No
If yes, give date, place and nature of each such event:
*
Are you currently excluded from participation in any federally funded healthcare program - including Medicare and Medicaid - and are you aware of any potential exclusion from a federally funded health program?
Yes
No
Education History
High School
*
Name of School:
*
City:
*
State:
*
Graduated/GED:
No
GED
Yes
Degree:
College
Name of School:
City:
State:
# of Years Completed:
1
2
3
4
5
Graduated:
n/a
No
Yes
Degree:
College
Name of School:
City:
State:
# of Years Completed:
1
2
3
4
5
Graduated:
n/a
No
Yes
Degree:
Graduate School
Name of School:
City:
State:
Attended:
1
2
3
4
Graduated:
n/a
No
Yes
Degree:
Other
Name of School:
City:
State:
Attended:
1
2
3
4
Graduated:
n/a
No
Yes
Degree:
Additional
Name of School:
City:
State:
Attended:
1
2
3
4
Graduated:
n/a
No
Yes
Degree:
List any professional licenses, registration or certification you possess (Include Driver's License, if applicable) Include Type, State Issued, Expiration Date and Number. Indicate if any licenses have been revoked, suspended or placed on probation. Also indicate if you are ineligible to become licensed or certified in your field. Please explain.
Clerical or other skills applicable to the position for which you are applying
Typing (WPM)
PBX
Proficient in Software:
Business machines and/or equipment you can operate:
Other