Applicant For Employment

APPLICANT FOR EMPLOYMENT

We are an equal opportunity employer. Pre-employment drug screen post offer physical, and background verification required. Qualified applicants are considered for all positions without regards to race, color, religion, sex, national origin, age, marital staus, disability, or any other legally protected status.

Date

Position(s) Applied For

How did you learn about us?
Advertisement Friend/Relative Employment Agency Walk-In Labette Health Employee

*First Name                *Middle Name

*Last Name                Suffix

*Street Address

Street Address 2

*City      *State      *Zip Code

*Home Phone                    Cell Phone
                                  Ex. (XXX-XXX-XXXX)                                                             Ex. (XXX-XXX-XXXX)

*email

yes no    Have you been convicted of a felony within the last 7 years? (Conviction will not necessarily
                         diqualify an applicant from employment.) If yes, explain


yes no    Were you previously employed by us?   If yes when?

yes no    Are you under 18 years of age? If yes, you will be required to provide proof of your eligibility
                          to work.

yes no    Are you excluded from participation in Medicare/Medicaid programs?

yes no    Are you prevented from lawfully becoming employed in this country because of Immigration
                          or Visa Status? Proof of citizenship or immigration status will be required upon employment.

yes no Are you able to perform the essential functions of job for which you are applying with or
without accommodation?

EDUCATION

School	Name and Address of School	Course of Study	Check Last Completed	Did You Graduate?	List Diploma or Degree
High			1 2 3 4	Yes No
College			1 2 3 4	Yes No
College			1 2 3 4	Yes No

Describe any specialized training, apprenticeship, skills and extra-curricular activities
Describe any honors you have received
State any additional information you feel may be helpful to us in considering your application

PROFESSIONAL LICENSES AND / OR CERTIFICATES

Are you currently: Registered Licensed Certified
Eligible For: Registration Licensure Certification

If Licensed, Registered or Certified	Type	State Issued	Date	No.	Exp. Date

Has your license of certification ever been suspended or revoked? Yes No
If Yes, When?

Did you serve in the U.S. Armed Services? Yes No What Branch?
Honorable Discharge? Yes No
Have you volunteered your time or services? Yes No Where?
Briefly describe duties and skills acquired through volunteer or military service: (include dates)

EMPLOYMENT

Please give accurate, complete full-time and part-time employment record. Start with your pressent or most recent employer.

Have you attended school or been employed under another name? Yes No
If so, under what name(s)?
Was there any gaps of unemployment between your previous jobs? Please describe.

Start with your present or last job.

Company Name
Address
Name of Supervisor
State Job Title and Describe Your Work

Phone Number
Employed - (State month and year)

Weekly pay
Reason for Leaving

Company Name
Address
Name of Supervisor
State Job Title and Describe Your Work

Phone Number
Employed - (State month and year)

Weekly pay
Reason for Leaving

Company Name
Address
Name of Supervisor
State Job Title and Describe Your Work

Phone Number
Employed - (State month and year)

Weekly pay
Reason for Leaving

Company Name
Address
Name of Supervisor
State Job Title and Describe Your Work

Phone Number
Employed - (State month and year)

Weekly pay
Reason for Leaving

We May contact the employers listed above unless you indicate those you do not want us to contact.

Employer: 1 2 3 4
Reason:

REFERENCES

List at least three references who have supervised you or can address your work record. Non-relative preferred.
Name and Relationship	Title	Company Name and Address	Telephone

I authorize the references listed above, schools and current and past employers to give Labette Health any and all information concerning my previous employment and any information they have, personal or otherwise, and I release all parties from all liabilities for any damage or claim that may result from furnishing the same to Labette Health.
*Authorized Signature *Confirm

APPLICANT'S STATEMENT
AND ACKNOWLEDGEMENT

I understand that, for purpose of employment only, Labette Health requires a back-ground check. I further understand a Consumer Report and/or an Investigative Consumer report may be made by a consumer reporting agency which may include, but is not limited to, information pertaining to my character, general reputation, personal characteristics, work habits, driving record, arrests and convictions, whichever may be applicable. This report may be compiled with information from court record repositories, department of motor vehicles, past or present employers and educational institutions, governmental occupational licensing or registration entities, business or personal references, National Practitioner Data Bank, Health and Humans Services Cumulative Sanctions report and any other source required to verify information that I have voluntarily supplied.

I understand if such an investigative report is made, and the report contains information regarding my character, general reputation, personal characteristics, I have the right to make a written request for a complete and accurate disclosure of the information and a copy of the report will be provided to me.

Also, I hereby understand and acknowledge unless otherwise defined by applicable law, any employment relationship with Labette Health is of an "at will" nature, which means the Employee may resign at any time and the Employer at any time may discharge Employee at any time, with or without cause. It is further understood this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged, in writing, by an authorized executive of Labette Health.

In the event of employment, I understand any false or misleading information given in my application or interview(s) may result in my discharge. I also understand I am required to abide by all rules and regulations of the employer. I understand employment is contingent upon favorable results of a post offer physical, medical tests (including, but not limited to, drug and alcohol screening) and background verifications, which must be completed prior to commencing employment at Labette Health.

I certify the answers given herein are true and correct to the best of my knowledge and belief.

*Signature of Applicant *Confirm *Date

REFERENCES RELEASE

To: Date:
To:
To:
To:

I hereby authorize you to furnish to Labette Health any information you may have available concerning my employment with your organization, and I release you from any liability for damages arising from said information.
*Signature of Applicant *Confirm