General Information

Last Name*

First Name*

Middle Name

Present Address*

City*

State*

Zip*

Any Previous Names

Phone Number*

Email Address*

Best Time to Contact You

AvailabilIty

Date Available for Work*

Select all that you would consider working*

Full Time / Regular Full Time / Temporary Part Time / Regular Part Time / Temporary Weekends & Holiday Rotating Shifts On Call Any Shift

Shift Availability*

Days Evenings Nights

Personal Details

Salary Desired*

How did you hear about this job?*

Long Range Occupational Goals*

Have you been employed by Pana Community Hospital before?*

Yes No

When?*

Are you a U.S. citizen or an alien legally authorized to work in the U.S.?*

Yes No

Are you 18+ years of age?*

Yes No

Relatives or friends employed in this facility?

Name

Department

Relationship

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Would you like to be considered for a comparable position in an alternate department if this posted position has been filled?*

Yes No

Education and Skills

Name of School*

Course of Study

Degree

High School / College*

Completed*

Graduate*

Yes No

+ Add Another Education

Additional Skills

Other Business College or Special Courses (include Special Military Training, Post Graduate and Nursing)

Area(s) of specialization or major interest*

List office skills including computer/software experience*

List health care, business, or industrial equipment operated*

Word processing (Approx. WPM)*

Briefly describe duties and skills acquired through military or volunteer service (include dates)

Licenses

License Status*

License Type

License Number

State*

Date

License or registration ever suspended, revoked or on probation?*

Yes No

If Yes, Explain*

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Certifications

Certification Status*

Certification Type

Certification Number

State*

Date

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Employment History

Provide information regarding previous employment beginning with most recent employer.

Check if Still Employed

Job Title*

From*

To*

Employer*

Phone Number*

Address*

Supervisor*

Duties*

Reason for Leaving*

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May we contact your current employer?*

Yes No

Please identify any gaps in employment longer than 3 months

Professional References

List at least 3 professional/work/school references who are not relatives or personal acquaintances.

Name*

Relationship*

Title*

Company*

Address*

Phone*

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Employment Form