Montgomery County Memorial Hospital
2301 Eastern Avenue, PO Box 498
Red Oak, IA 51566
Fax (712) 623-7139
Phone (712) 623-7238

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status. (PLEASE PRINT OR TYPE)

Position

Date

 

Last Name, First, Middle

 

Complete Address

 

Telephone Numbers

 

Social Security Number

Best time to contact you at home .…………………………………..………….…………. ____:____ AM/PM

If under 18 years of age, can you provide required proof of eligibility to work? ………..…..... Yes  /  No

Have you filed an application with us before? ..…………………………………………..……... Yes  /  No
If yes, give date __________________

Have you ever been employed with us before? ...………………………………………..…...… Yes  /  No
If yes, give date __________________

Do any of your friends or relatives, other than spouse, work here? ……………………..……. Yes  /  No

Are you currently employed? ……………………………………………………….…...……..….. Yes  /  No

Are you currently on "lay-off" status and subject to recall? ……………..…..………..…..……. Yes  /  No

May we contact your present employer? ……………………………………….……...…..…….. Yes  /  No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status?
(Proof of citizenship or immigration status will be required upon employment) ….……....….. Yes  /  No

Date available for work ____/____/____  What is your desired salary range? ____________________

Please indicate when you are available to work:
Full-time - 1st, 2nd, 3rd shift
Part-time - Morning, Afternoon, Evening
Temporary - Dates Available: ___/___/___ - ___/___/___

 


EDUCATION

School

Name and Address of School

Degree/Years Completed

Elementary

 

 

 

 High School

 

 

 

 Undergraduate College

 

 

 

 Graduate Professional

 

 

 

 Other (specify)

 

 

 

 

EMPLOYMENT EXPERIENCE

If the following information is listed on your resume please submit a copy with this application.  If you do not have a resume, please attach a separate summary of your work history. Start with your present or last job, and complete the required fields listed below. Please include any job-related specialized skills, qualifications, equipment operated, military, professional, trade, business, volunteer, or civic activities and offices held. (You may exclude any membership which would reveal gender, race, religion, national origin, age, ancestry, disability, or other protected status.)

The following items are required for each past job you have held:

  1. Employer name and complete mailing address
  2. Supervisor name and telephone number
  3. Job title or position held
  4. Dates of employment
  5. Hourly rate or salary
  6. Reason for leaving
  7. Work performed

 


REFERENCES (Please list 3 personal references. Additional business/professional may also be listed.)

Name and Mailing Address

Phone Number and E-mail Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICANT'S STATEMENT AND CONSENT

I certify that answers given herein are true and complete. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that 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 this organization.

In the event of employment, I understand that false or misleading information given in my application or interviews may result in discharge. I understand, also, that I am required to abide by all rules or regulations of the employer.


___________________________________________
Signature of Applicant


_______________________________
Date