Personal InformationLast Name*First Name*Phone*Email Street Address*City*State*Zip*Social Security Number*Are you authorized to work in the U.S.?*YesNoHave you ever been convicted of a felony?*YesNoIf yes, please explain.*Are you a veteran?*YesNoBranch, MOS, and Type of dischargeDesired PostionTitle of PositionDesired Salary or Wage*Date You Can Start*What type of work do you want?* Full Time Part Time Specify the days and hours you would like to work.*Did someone refer you to this position? If so who can we thank?How did you hear about this position?*Herington Municipal Hospital WebsiteEmployment AgencyRadioNewspaperOtherWhich specific one(s) did you hear about the position from?Educational BackgroundHigh SchoolName of High SchoolLocation of High SchoolSubjects (If applicable)Dates AttendedDid you graduate?YesNoHigher EducationName of College, University, or Tech SchoolLocationSubjects (If applicable)Dates AttendedDid you graduate?YesNoName of College, University, or Tech School #2 (if applicable)LocationSubjects (If applicable)Dates AttendedDid you graduate?YesNoEmployment HistoryAre you currently employed?*YesNoMay we contact your present employer?*YesNoHave you ever worked for Herington Municipal Hospital?*YesNoWhen did you work for Herington Municipal Hospital?*Why did you leave Herington Municipal Hospital?*Previous Employer 1* Company Name Address Ending Salary Position Held Reason for Leaving*Dates Employed* From To Previous Employer 2 Company Name Address Ending Salary Position Held Reason for LeavingDates Employed From To Previous Employer 3 Company Name Address Ending Salary Position Held Reason for LeavingDates Employed From To List any volunteer or community service positions (work) which you feel are related to the position for which you are applying.Briefly state any special skills or qualifications you have which you feel are related to the position for which you are applying.Personal ReferencesGive below the names of three persona not related to you, whom you have known at least 1 year.Reference 1* Reference Name Occupation Address Phone Number Reference 2* Reference Name Occupation Address Phone Number Reference 3* Reference Name Occupation Address Phone Number Other filesWould you like to upload a cover letter?Accepted file types: doc, docx, pdf.Upload other files that you think will be beneficial. Drop files here or Accepted file types: docx, doc, pdf. Certification & AuthorizationThis institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, sexual preference, ancestry, Vietnam era veteran status, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination. I certify that my answers are true and complete to the best of my knowledge. I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I consent to take the physical examination and drug screen and such future physical examinations as may be required by this institution at such times and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physician examination which relates to the essential duties I would be required to perform. I understand that my employment is at will and that either party is free to terminate the employment relationship at any time without cause. I understand that my employment may be terminated for any misstatement or omission of fact appearing on this application formSignature*Date* MM DD YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged.