Application for Employment
* required info
Personal Information
Application Date Monday Sep 06, 2010 at 9:49:31 PM
Date Available: *
First Name: *
Middle Name: *
Last Name: *
Street Address: *
City: *		State: *		Zip: *
Home Phone Number: *		Alternate Phone Number:
E-Mail Address:
Position(s)Applying For: *
Will you accept employment of: *	Full Time Part Time Temporary
Are you 18 years of Age or older? *	Yes No
If not, are you at least 16? *	Yes No
Have you every been employed by Grundy County Memorial Hospital? *	Yes No
Have you ever worked under another name? *	Yes No
If yes give name(s):
Have you been employed by any Iowa Health System affiliate? If so please specify *	None Allen Hospital The Finley Hospital Iowa Health - Des Moines Iowa Health Home Care Iowa Health Physicians Iowa Health System St. Luke's Regional Medical Center St. Luke's Hospital Trinity Regional Medical Center Trinity Regional Health System
Position(s) held:
Date(s) of employment:
How did you learn of this opening?	Newspaper Referred by an Employee Recruiter Company Website Job Board Job Website Other
If other, please be specific:
Shifts you are willing to work: *	1st Days 2nd Evenings 3rd Nights Weekends Holidays Rotate Days
Education
HIGH SCHOOL
Name of School:		Location (City/State):
Course of Study:		Graduated?	Yes No
Type of degree of certificate received:
Attended from:
Attended to:
COLLEGE/UNIVERSITY
Name of School:		Location (City/State):
Course of Study:		Graduated?	Yes No
Type of degree of certificate received:
Attended from:
Attended to:
VOCATIONAL OR BUSINESS
Name of School:		Location (City/State):
Course of Study:		Graduated?	Yes No
Type of degree of certificate received:
Attended from:
Attended to:
OTHER
Name of School:		Location (City/State):
Course of Study:		Graduated?	Yes No
Type of degree of certificate received:
Attended from:
Attended to:
Professional Licenses and/or Certifications
Type:
License/Cert. Number:
State Issued:
Expiration Date:
Type:
License/Cert. Number
State Issued:
Expiration Date:
Type:
License/Cert. Number
State Issued:
Expiration Date:
Is your professional license or has it ever been under investigation suspended or revoked in this state or any other *	Yes No
If yes please explain. (Failure to disclose will result in disqualification from employment)
Employment Record (list last or present position first)
Give a complete record of your most recent employment, include volunteer work,, military service, etc. Start with the present or most recent employer. Use the space provided.
Are you currently employed? *	Yes No
May we contact your present employer for reference? *	Yes No
If no please explain or if not at this time please give a date when contact may occur
Company Name:
Address:
City:
State:
Zip:
Telephone:
Name of Supervisor/Title:
From:
To:
Hourly Pay/Salary
Full Time/Part Time/PRN?	Full Time Part Time PRN
Position Held and Describe Duties:
Reason for Leaving?
Company Name:
Address:
City:
State:
Zip:
Telephone:
Name of Supervisor/Title:
From:
To:
Hourly Pay/Salary
Full Time/Part Time/PRN?	Full Time Part Time PRN
Position Held and Describe Duties:
Reason for Leaving?
Company Name:
Address:
City:
State:
Zip:
Telephone:
Name of Supervisor/Title:
From:
To:
Hourly Pay/Salary
Full Time/Part Time?	Full Time Part Time PRN
Position Held and Describe Duties:
Reason for Leaving?
Company Name:
Address:
City:
State:
Zip:
Telephone:
Name of Supervisor/Title:
From:
To:
Hourly Pay/Salary
Full Time/Part Time?	Full Time Part Time PRN
Position Held and Describe Duties:
Reason for Leaving?
Company Name:
Address:
City:
State:
Zip:
Telephone:
Name of Supervisor/Title:
From:
To:
Hourly Pay/Salary
Full Time/Part Time?	Full Time Part Time PRN
Position Held and Describe Duties:
Reason for Leaving?
Additional References
Name:
Relationship to Applicant/Title:
Telephone Home:
Telephone Work:
Organization:
Address:
Name:
Relationship to Applicant/Title:
Telephone Home:
Telephone Work:
Organization
Address:
Criminal Abuse/History
The existence of a criminal record will not automatically disqualify an applicant from employment. The circumstances of a conviction will be considered in relation to the nature and duties of the job for which you apply. ***Failure to disclose will result in disqualification for employment.***
Do you have a record of founded child or dependent adult abuse in this state or any other state?*	Yes No
If yes explain (give dates):
Have you ever been convicted of a crime in this state or any other state? (You are not required to reveal records that have been expunged, sealed or impounded under Illinois law or any other state). *	Yes No
If yes, please explain offense and identify the state in which the offense occurred, provide dates and final disposition.
Have you ever been excluded from or been served with an exclusionary notice of any governmental programs., ie. Medicare?*	Yes No
If yes, explain (give dates):
Citizenship
Are you a Citizen of the United States or authorized to be employed in the United States? *
Type of Visa
Registration Number:
* required info
Signature
Grundy County Memorial Hospital operates 24-hours a day, seven days a week. Assignment of shifts, hospital units, days off and other conditions of employment are generally made on basis of availability, tenure, and ability in each job classification. Each employee is required to comply with staffing assignments. As work changes occur within departments or hospital-wide, employees may be required to change shifts and/or days worked temporarily, or on a regular basis. By signing below, I certify that the answers and information set out above are true, accurate and complete to the best of my knowledge. I acknowledge that if any answer or information is not true, accurate or complete, I may not be hired, or if hired, I may be discharged. I authorize the employer to investigate all statements contained in this application for employment to include criminal, child and dependent adult abuse information in accordance with Iowa Code, Section 134C.33, as well as my character and qualifications. I release the employer from all liability for actions performed in good faith and without malice in connection with evaluation of my application. I authorize my prior employers, references, and others with information regarding my work, educational history or my character, to provide the employer with all information requested and to cooperate fully with the investigation of my character and qualifications. I agree to cooperate in such an investigation, and release from all liability and/or responsibility all persons, companies, or corporations supplying such information. I understand that if I am offered employment, the offer is contingent upon receipt of satisfactory employment references, acceptable criminal/abuse/compliance background information, favorable health evaluation and, when applicable, a physical examination which may include a drug test (urinalysis) provided by Iowa Health System. I understand that this application is not a contract of employment. If hired, my employment and compensation can be terminated at will, with or without a showing of cause, and with or without notice by myself or my employer. I agree that if employed, I will abide by all policies, procedures, rules, and regulations established. I acknowledge that information contained in the official employee record is shared with authorized individuals within Iowa Health System and its affiliates. I understand that if I am hired, I will be required to identify a financial institution into which my payroll check will be electronically deposited each pay period. This is desirable but not required for Illinois residents. Grundy County Memorial Hospital seeks to provide a healthy, comfortable, and productive work and health care environment. In the event I am hired as an employee of Grundy County Memorial Hospital, Inc., I acknowledge and agree to abide by Grundy County Memorial Hospital, Inc.'s Tobacco-Free Environment Policy. I understand that smoking or any tobacco use is strictly prohibited anywhere on the Grundy County Memorial Hospital campus.
Applicant/Electronic Signature *
Date *