Job Application Perry, Iowa (IA), Dallas County Hospital

Personal Information

Date of Application^*

Position Applying For^*

Last Name^*

First Name^*

Middle Initial^*

Email^*

Home Address^*

City^*

State

Zip^*

Phone^*

Are you a US Citizen? No Yes

Are you 18 or older? No Yes

How did you hear about this position?

LIST ANY REASON(S) WHY YOU MIGHT BE UNABLE TO PERFORM ANY DUTIES OF THIS POSITION CONSISTENTLY AND PROMPTLY.

Date Available to Work^*

Starting Salary Needed^*

Are you willing to accept other positions?
No Yes

If Yes, please specify

If Yes, when?

Which location?

What position?

Under what name were you employed?

Do you have a friend or relative working here?
No Yes

Please list name, dept., and relationship to you.

Have you ever been CONVICTED of a crime?
No Yes

If Yes, list date(s), offense(s), and dispositions

HAVE YOU EVER BEEN EXCLUDED FROM PARTICIPATION IN ANY FEDERAL OR STATE MEDICARE, MEDICAID OR ANY OTHER THIRD PARTY PAYOR PROGRAM OR HAVE SUCH PENDING ACTION? IF YES, A LETTER SHOWING REINSTATEMENT IS REQUIRED FOR FURTHER CONSIDERATION FOR EMPLOYMENT.
No Yes

Employment History

List most recent first.

Name of Employer

From

Address, City, State, Zip of Employer

Name and Title of Last Supervisor

Supervisor/Employer Phone

Position Held

Ending Salary

Briefly describe the work you performed.

Reason for leaving

Name of Employer

From

Address, City, State, Zip of Employer

Name and Title of Last Supervisor

Supervisor/Employer Phone

Position Held

Ending Salary

Briefly describe the work you performed.

Reason for leaving

Name of Employer

From

POSITION APPLYING FOR:

DATE OF APPLICATION:

PERSONAL

LAST NAME:

FIRST NAME:

MIDDLE INITIAL:

HOME ADDRESS:

CITY:

STATE:

ZIP:

PHONE:

US CITIZEN:

OVER 18:

HOW DID YOU HEAR ABOUT THIS POSITION?

LIST ANY REASON KNOWN TO YOU WHY YOU MIGHT NOT BE ABLE TO PERFORM CONSISTENTLY AND PROMPTLY ANY OF THE DUTIES:

DATE AVAILABLE:

STARTING SALARY NEEDED:

WILL YOU ACCEPT ANOTHER POSITION?

IF YES, SPECIFY:

WILL YOU ACCEPT SHIFT WORK?

WHICH TYPES OF POSITIONS WILL YOU ACCEPT? FULL TIME PART TIME TEMPORARY

WILL YOU ACCEPT WEEKEND WORK?

WERE YOU PREVIOUSLY EMPLOYED AT A DCH FACILITY?

IF YES, WHEN?

WHERE?

POSITION?

UNDER WHAT NAME?

FRIEND OR RELATIVE WORKING HERE? - NAME, DEPT, RELATIONSHIP:

HAVE YOU EVER BEEN CONVICTED OF A CRIME?

IF YES, GIVE DATES, OFFENSE(S) AND DISPOSITIONS:

HAVE YOU EVER BEEN EXCLUDED FROM PARTICIPATION IN ANY FEDERAL OR STATE MEDICARE, MEDICAID OR ANY OTHER THIRD PARTY PAYOR PROGRAM OR HAVE SUCH PENDING ACTION?

IF YES, A LETTER SHOWING REINSTATEMENT IS REQUIRED FOR FURTHER CONSIDERATION FOR EMPLOYMENT:

EMPLOYMENT HISTORY

LIST MOST RECENT FIRST; LIST OTHER NAMES WHILE EMPLOYED WITH THESE EMPLOYERS.

FROM MONTH:

FROM YEAR:

NAME OF EMPLOYER:

NAME/TITLE OF LAST SUPERVISOR:

TO MONTH:

TO YEAR:

ADDRESS:

PHONE:

POSITION HELD:

ENDING SALARY:

BRIEFLY DESCRIBE THE WORK YOU PERFORMED:

REASON FOR LEAVING:

FROM MONTH:

FROM YEAR:

NAME OF EMPLOYER:

NAME/TITLE OF LAST SUPERVISOR:

TO MONTH:

TO YEAR:

ADDRESS:

PHONE:

POSITION HELD:

ENDING SALARY:

BRIEFLY DESCRIBE THE WORK YOU PERFORMED:

REASON FOR LEAVING:

FROM MONTH:

FROM YEAR:

NAME OF EMPLOYER:

NAME/TITLE OF LAST SUPERVISOR:

TO MONTH:

TO YEAR:

ADDRESS:

PHONE:

POSITION HELD:

ENDING SALARY:

BRIEFLY DESCRIBE THE WORK YOU PERFORMED:

REASON FOR LEAVING:

EDUCATION

NAME OF SCHOOL	LOCATION	YEARS COMPLETED	DATES	COURSE OF STUDY	GRADUATE	DEGREE
ELEMENTARY:
HIGH SCHOOL:
TRADE:
COLLEGE:
GRADUATE:
PROFESSIONAL:
BUSINESS:
OTHER:

PROFESSIONAL LICENSES, REGISTRATION, AND/OR CERTIFICATIONS DO NOT INCLUDE DRIVERS LICENSE.

TYPE	STATE ISSUED	DATE ISSUED	EXPIRES	NUMBER	ELIGIBLE

APPLICANT'S CERTIFICATION
I certify that all matters contained in this application are true, and that any misleading or false statements would render this application void and would be sufficient cause for immediate dismissal in the event of employment. I understand that this is an application for employment and that no employment contract is being offered. I hereby authorize DCH to investigate all matters contained in this application and to contact prior employers to obtain any and all information related to my past performance. I agree, if employed, to abide by all Dallas County Hospital rules and regulations. I understand that such employment is for an indefinite period of time and that the company can change wages, benefits and conditions of employment at any time. I understand that I am required to immediately notify DCH if any action is proposed to exclude me from participation in any federal or state Medicare, Medicaid or third party payor program. I have read and understand the above.
DATE:	SIGNATURE:

APPLICANT'S CERTIFICATION

I certify that all matters contained in this application are true, and that any misleading or false statements would render this application void and would be sufficient cause for immediate dismissal in the event of employment.

I understand that this is an application for employment and that no employment contract is being offered.

I hereby authorize DCH to investigate all matters contained in this application and to contact prior employers to obtain any and all information related to my past performance.

I agree, if employed, to abide by all Dallas County Hospital rules and regulations. I understand that such employment is for an indefinite period of time and that the company can change wages, benefits and conditions of employment at any time.

I understand that I am required to immediately notify DCH if any action is proposed to exclude me from participation in any federal or state Medicare, Medicaid or third party payor program.

I have read and understand the above.

DATE:

SIGNATURE:

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Job Details

Dallas County Hospital

Job Application

Graduate School

Professional

Business

Other

Professional Licenses, Registration, and/or Certifications

Signature

Job Details

Dallas County Hospital

Job Application

Personal Information

Employment History

Education

Elementary

High School

Trade School

College

Graduate School

Professional

Business

Other

Professional Licenses, Registration, and/or Certifications

Signature

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