Application - Sullivan County Memorial Hospital

630 W 3rd Street Milan, MO 63556

APPLICANT TO COMPLETE ALL INFORMATION REQUESTED.

In compliance with Federal and State employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status disability or any other protected group status.

APPLICATION FOR EMPLOYMENT

Please list any other name(s) which you have been known by at previous employers or educational institutions:

Do you currently use tobacco/nicotine products?**

No Yes

Do you have a legal right to be employed in the United States?

No Yes (proof required)

Are you over the age of 18?

No Yes

Have you ever been convicted of a felony?

No Yes

If yes, please explain:

Have you ever been excluded from providing patient care to those receiving Medicare or Federally funded health care programs?

No Yes

If yes, please explain:

Do you have a record of founded child or dependent adult abuse?

No Yes

If yes, please explain:

Have you worked for Sullivan County Memorial Hospital before?

No Yes

Are you currently employed?

No Yes

If not, last date of employment?

Position applying for?

Time Availability

If applying for part-time, hours available per week:

How did you become aware of this position?

Rate of pay expected:

Available start date:

Did you graduate?

No Yes

Grad School Name & City

Did you graduate?

No Yes

Technical School Name & City

Did you graduate?

No Yes

Highschool Name & City

Did you graduate?

No Yes

Did you graduate?

No Yes

LIST ALL PRESENT AND PAST EMPLOYMENT, BEGINNING WITH MOST RECENT

Current Employer Name

Duties & Responsibilities

Previous Employer Name

Duties & Responsibilities

Relationship & Title

Special Skills

Please check the skills for which you have received training

Speak, read, or write any language other than English?

Health Care Equipment

If applicable, any other professional credentials that would relate to the position for which you are applying:

APPLICATION FOR EMPLOYMENT

GENERAL

Employee HealthStream Login