Secure Application for Employment
Human Resources Department
510 North Green Street
Valentine, Nebraska 69201
It is the policy of this facility to provide equal opportunity to persons regardless of race, color,
religion, gender, sexual orientation, gender identity, national origin, veteran or disability status
or any other classification in accordance with federal, state and local statues, regulations, and ordinances.
http://www.cherrycountyhospital.org
email: 
Date
This application can be active as long as legally required.
Last Name                                    First Name                                  Middle Initial
   
Are You At Least 18 Years Old?

Home Phone And Cell Phone

Present Address

Present City

Present State

Present Zip Code

E-Mail Address

Previous Address

Previous City

Previous State

Previous Zip

Current Open Position(s) for Which You Are Applying



Type of Position
Per Diem
Pool
Full Time
PRN
Part Time
Temporary
Shift

Weekend
Day
Night
Evening
Rotation
Salary Requirement
$
Are You Willing To Travel?

Are You Willing To Relocate?

Do you have the ability to report to work on time each day, including when called in on short notice?
If overtime work is required periodically, does this pose a problem for you?
Date Available For Work

Are You Legally Authorized to Work in the U.S.?
Have you ever worked in this or any other facility of CCH?
If yes, what facility? Are you related to another facility employee?
How did you learn about this position?
State Employment
         Commission
Internet
Agency
Ad
Job Listing
School
Job Line
Current Employee
Please insert the employee's name:
Other:

Are you able to meet the attendance requirements of the position?

Please review the job description for the position for which you are applying. Are you able to perform the essential, job related functions of the position?
Please describe any reasonable accommodations which may be necessary:

Within the last seven (7) years, have you been convicted of a crime or violation other than a minor traffic infraction?
(No applicant will be denied employment solely on the grounds of conviction of a criminal offense.
The date of the offense, the nature and severity of the offense, including any significant details
that affect the description of the event, the surrounding circumstances and the relevance of the offense
to the position(s) applied for may, however, be considered.)
Arrests or charges that have been expunged need not be disclosed.
Applicants are not obligated to disclose any sealed criminal record.

If yes, please explain the circumstances of the conviction(s) including the date, nature, place of the offense,
disposition and any other relevant information.


Are you currently excluded from participation in any federally funded healthcare program - including Medicare and Medicaid?
Are you aware of any potential exclusion from a federally funded health program?
Educational History
Type of School
Name of School

City, State
Check Last Year
Attended in School

Degree or Certificate
High School
School:
    City:
   State:
9   10   11   12
Graduated/GED?
Degree:
College
School:
    City:
   State:
1     2     3    4
Graduated?
Degree:
College
School:
    City:
   State:
1    2    3     4
Graduated?
Degree:
Graduate
School

School:
    City:
   State:
1    2     3    4
Graduated?
Degree:
Other
School:
    City:
   State:
1    2    3    4
Graduated?
Degree:
Other
School:
    City:
   State:
1    2    3    4
Graduated?
Degree:
List any professional licenses, registration or certification you possess
(Include Driver's License, if applicable to the position)
Include Type, State Issued, Expiration Date and Number.
Indicate if any licenses have been revoked, suspended or placed on probation.
Also indicate if you are ineligible to become licensed or certified in your field. Please explain.

Clerical or other skills applicable to the position for which you are applying
Typing (WPM)              PBX
Proficient in Software: 
Business machines and/or equipment you can operate:
      
Other