APPLICATION FOR EMPLOYMENT
NOTE: COMPLETE ALL PARTS OF THE APPLICATION. IF YOUR APPLICATION IS INCOMPLETE, OR DOES NOT
CLEARLY SHOW THE EXPERIENCE AND/OR TRAINING REQUIRED, YOUR APPLICATION WILL NOT BE
First Middle Last Are you at least 18 years old? Per CMS Final Rule, all Gove County Medical Center employees must be vaccinated against COVID-19 or receive an approved medical/religious exemption prior to the first day of employment; are you able to comply with this requirement? * Phone * Email *
Present Address * Previous Address Current open position(s) for which you are applying * Location How did you hear about this job opportunity? (Please specify ad or other source.) Type of position Shift Are you willing to travel? Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours? * If overtime work is required periodically, does this pose a problem for you? Date available for work
MM slash DD slash YYYY Are you legally authorized to work in the U.S.? Have you ever worked in this facility? If yes, what department? Are you related to another facility employee? Are you able to perform the essential, job related functions of the position for which you are applying with or without reasonable accommodations? Describe any accommodations necessary: Have you been convicted of a crime and/or released from confinement following a conviction for any criminal offense?
Arrests or charges that have been expunged need not be disclosed.
If yes, give date, place and nature of each such conviction. Are you presently charged with any violation of the law? If yes, give date, place and nature of each such event: Are you currently excluded from participation in any federally funded healthcare program - including Medicare and Medicaid - and are you aware of any potential exclusion from a federally funded health program? Have you ever been terminated from employment or asked to resign by an employer? How many hours per week are you available to work? (Must indicate exact amount, no range) Are you able to report to work punctually and regularly? Please explain. Times available to work. (Be specific as to hours and days.) What days and times are you not able to work? Have you had any previous experiences or contacts with our Company? Please explain any lapses in prior employment. Why would you like to work for the Company? Employment History Please include your four (4) most recent employers. Do not omit any employers. Educational History Please list your educational history List any professional licenses, registration or certification you possess List any other skills applicable to the position for which you are applying Do you have any computer skills? If yes, please describe. References Please list references from your previous work or education Please upload your resume Please upload your cover letter Consent I understand and agree to the terms.
By checking the box above, I certify that all answers to questions in the application, and other reference documents referenced above are true and complete to the best of my knowledge. I understand that misrepresentation, omission, or falsified statements on this Application or any other reference documents in any detail shall constitute sufficient cause for disqualification from further consideration for hire or for dismissal whenever discovered.
ADDITIONAL DISCLOSURES AND AGREEMENTS I understand and agree to the terms.
I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States, and that federal immigration laws require me to complete an I-9 Form in this regard. I further understand that to be eligible for employment, I must complete the entire application process which may include a medical examination, drug test, and background investigation.
I expressly authorize, without reservation, the Company, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or provided during the job interview. I hereby waive any and all rights and claims I may have regarding the Company, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me. In order to process your application, or during the course of your employment, a consumer report may be obtained on you for employment purposes. It may be an investigative consumer report that includes information regarding your character, general reputation, personal characteristics, and mode of living. Such report may also be necessary in relation to any investigation regarding allegations of sexual harassment, discrimination, or disciplinary charges associated with your employment. The employer may utilize an outside organization to obtain a consumer report and/or to conduct investigations. If an investigative consumer report is obtained, you have a right to request disclosure of the nature and scope of the report, which involves personal interviews with sources such as your neighbors, friends, or associates. I hereby authorize the employer to obtain a consumer report on me for employment purposes and to conduct investigations as outlined above. I understand that the Company may perform a criminal background check on me. I consent to the background check. I hereby waive any and all rights and claims I may have regarding the Company, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that the Company does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law. I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the Company and still wish to be considered for employment, it will be necessary for me to reapply and complete a new application. In consideration of my employment, I agree to conform to the company’s rules and regulations, and I agree that I am an “at will” employee which means that my employment and compensation can be terminated, with or without cause, and with our without notice, at any time, at either my or the company’s option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company. I understand that no company representative, other than its President, and then only when in writing and signed by the President, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing. I further agree that I may not enter into any other employment or engage in any business which will conflict with my responsibilities as an employee of Company. CRIMINAL BACKGROUND CHECK POLICY AND DISCLOSURE I understand and agree to the terms.
As a condition of employment, I may be subject to a criminal background check. I give my consent to perform a criminal background check.
In conducting criminal background checks, Company will comply with federal laws that protect applicants and employees from discrimination. That includes discrimination based on race, color, national origin, sex, LGBQT status, religion; disability; genetic information (including family medical history); and age (40 or older). In addition, Company, to the extent required, will comply with the Fair Credit Reporting Act (FCRA) with regard to conducting criminal background checks. The Federal Trade Commission (FTC) enforces the FCRA. Although a disqualification is possible, in accordance with federal and state laws, a previous conviction does not automatically disqualify an applicant from consideration for employment with Company, unless such employment involves working with children and the conviction or criminal conduct relates to children or is clean record is required given the job duties, funding source, or employment source. In conducting criminal background checks and convictions, Company complies with the EEOC guidelines regarding the use of criminal background checks. To the extent that the criminal background check reveals conduct that would exclude the person from the specific job applied for after applying the “Green Factors,” and to the extent that the basis for denying the job was related to the criminal background check, Company will send out an appropriate letter to the prospective employee explaining the basis for denial of the job. The prospective employee shall have ten days after the date of the correspondence explaining the basis for denial of the job to contact the Company and schedule a meeting explaining how the criminal background conduct should not exclude him/her. Failure by the prospective employee to contact Company within the ten (10) day period as provided above, shall constitute of waiver of such right to engage the Company regarding the decision to deny employment. If you have any questions regarding your rights, please feel free to contact the Human Resource Department at the Company or the EEOC at www.eeoc.gov. By checking the box above, I permit the Company to perform a criminal background check and certify that all answers to questions in the application, and other reference documents are true and complete to the best of my knowledge. I understand that misrepresentation, omission, or falsified statements on this application or any other reference documents in any detail shall constitute sufficient cause for disqualification from further consideration for hire or for dismissal whenever discovered. Equal Opportunity
Gove County Medical Center is an Equal Opportunity Employer (EOE). Gove County Medical Center provides equal employment and advancement opportunities to all qualified staff members and applicants for employment without respect to race, color, religion, national origin, LGBTQ status, veteran status, sex, age, disability, or any other protected class under the law. Gove County Medical Center does not condone and will not tolerate discrimination, intimidation, or harassment based on these factors and sexual harassment is prohibited whether directed toward women or men. Such conduct will subject the employee to disciplinary action, up to and including immediate termination. We do not tolerate any employee engaging in harassment or discrimination of any kind. Please see our “Non-Discrimination and Anti-Harassment Policy” and our “Sexual Harassment Policy”. Gove County Medical Center will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in an undue hardship. The policy governs all aspects of employment, including selection, job assignment, compensation, discipline, termination, and access to benefits and training.
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