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Online Application

Crawford County Memorial Hospital - An equal opportunity employer

Instructions: Please fill out all form fields and complete every part of this application. If there is a question which does not apply to you, enter "N/A"; do not leave any question unanswered.

Any false, misleading, or incomplete responses may result in disqualification for hire or immediate dismissal from employment. You may add additional information near the end of the form.

*required fields

Position(s) applied for:
*Primary Position:
*Expected Pay Rate:
Secondary Position:
Expected Pay Rate:
Todays Date:
 2/6/2012
Date you can start:
How did you learn about this job?
Personal Information
*First Name:
*Last Name:
Middle Initial:
*Home Address:
*City:
*State:
*Zip Code:
*Home Phone:
Other Phone:
*Email Address:
*Social Security Number:
Are you available:
Check all that apply
 Full-time
Part-time
Temporary
Please describe any work schedule limitations:
(Can you alternate between shifts? Can you work overtime?)
Have you ever been employed by us before?

If yes, start date:
Do you have any relatives employed by us?

If yes, list relatives:
Are you at least 18 years old?

Do you have a record of founded child or dependent adult abuse or have you ever been convicted of a crime other than a simple misdemeanor offense relating to motor vehicles and laws of the road under chapter 321 or equivalent provisions in this state or any other state??
If yes, list as follows:
Note: A conviction record will not necessarily disqualify an applicant from employment. The circumstances of the conviction will be considered in relation to the nature and duties of the job applied for.
Are you lawfully authorized to work in the U.S.?
Note: The law requires that you provide evidence and a sworn statement of your citizenship or work authorization if you are hired. Any offer of employment which you receive is contingent upon your providing the documentation and statement which we will request from you.
Do you have a valid driver's license?
   
Prior Employment

List your last four jobs, beginning with the most recent.

Note: In order to give past experience credit a complete work history will be needed.

   
(1) Employer Name:
Supervisor:
Phone:
Street Address:
City:
State:
Zip Code:
Job Title:
Duties:
Dates Employed:  
From:
To:
Rate of Pay:
What you liked most about your job?
What you liked least about your job?
Reason for leaving:
   
(2) Employer Name:
Supervisor:
Phone:
Street Address:
City:
State:
Zip Code:
Job Title:
Duties:
Dates Employed:  
From:
To:
Rate of Pay:
What you liked most about your job?
What you liked least about your job?
Reason for leaving:
   
(3) Employer Name:
Supervisor:
Phone:
Street Address:
City:
State:
Zip Code:
Job Title:
Duties:
Dates Employed:  
From:
To:
Rate of Pay:
What you liked most about your job?
What you liked least about your job?
Reason for leaving:
   
(4) Employer Name:
Supervisor:
Phone:
Street Address:
City:
State:
Zip Code:
Job Title:
Duties:
Dates Employed:  
From:
To:
Rate of Pay:
What you liked most about your job?
What you liked least about your job?
Reason for leaving:
 
Education and Training
List high school, technical, or trade school, college, and postgraduate education, if any.
(1) School/College
Level Completed
Degree
Major Subjects
(2) School/College
Level Completed
Degree
Major Subjects
(3) School/College
Level Completed
Degree
Major Subjects
(4) School/College
Level Completed
Degree
Major Subjects
(5) School/College
Level Completed
Degree
Major Subjects
 
Other Skills
Describe any computer, office machine, tool, or equipment skills and proficiency level:
Describe any other special skills or qualifications which may help you in the position applied for (including continuing education not resulting in a degree, certificate, etc.,):
List all professional licenses of certificates held including State, license or certificate type, date issued, license or certificate number, and expiration date:
List any relevant professional or business organizations to which you belong (optional):
 
Veteran Status
If you are a veteran of the armed forces of the United States, please provide the following information:
Military Branch:
Dates of Service:
  
From:
To:
Discharge Date:
   
References
List three references, 2 professional, and 1 personal reference that you have known for more than one year, other than relatives, who we can contact.
(1) Professional  
Name:
Phone:
How long known:
Occupation:
(2) Professional  
Name:
Phone:
How long known:
Occupation:
Personal  
Name:
Phone:
How long known:
Occupation:
   
Additional Information
You may add any additional relevant information in the box below.
Please explain any unemployment lasting longer than 60 days and/or involuntary terminations in the past 5 years.
Crawford County Memorial Hospital

By submitting this form, 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 Crawford County Memorial Hospital to investigate all statements contained in this application for employment and to investigate my character and qualifications to include criminal, child and dependent adult abuse information in accordance with Iowa law. I authorize my prior employers, references, and others with information regarding my work, educational history or my character, to provide Crawford County Memorial Hospital with all requested information and references, and to cooperate fully with the investigation of my character and qualifications.

I understand that this application is not a contract of employment. I also acknowledge that no oral representations have been made, and that no one within Crawford County Memorial Hospital has the authority to make oral contracts of employment. If hired, my employment relationship with Crawford County Memorial Hospital is terminable at-will, with or without cause, by either myself or Crawford County Memorial Hospital.

I also understand that my employment may be conditioned upon a favorable criminal background check and health examination which may include a drug screen and a medical examination by a physician selected by this employer, to which I hereby consent.

I understand that if I am hired, I will be required to identify a financial institute into which my payroll checks will be electronically deposited each pay period.

Crawford County Memorial Hospital is committed to providing a healthy and comfortable, and productive environment. In the event that I am hired as an employee of Crawford County Memorial Hospital, I acknowledge and abide by Crawford County Memorial Hospital’s “Tobacco-Free Environment” Policy. I understand that the use of tobacco products is strictly prohibited anywhere on the campus of Crawford County Memorial Hospital.

I understand and agree to all the conditions and statements set forth above, and throughout this application.
*Full Name:
*Date and Time: