Secure Application for Employment
HR7940 Rev 07/02
Human Resources Department
1400 W Fourth St.
Coffeyville, KS 67337
It is the policy of this facility to provide equal opportunity to persons regardless of race, religion,
age, gender, disability or any other classification in accordance with federal, state and local        
statutes, regulations and ordinances.                                                                                       
http://www.crmcinc.com
email:  michellek@crmcinc.org
Date
This application can be active as long as legally required.
Last Name                                    First Name                                  Middle Initial
   
Are You At Least 18 Years Old?

Last 4-digits of
Social Security Number


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
On-call
Full Time
Part Time
Temporary
Shift

Weekend
Day
Night
Evening

Minimum Salary Expected
$ per hour
Are You Willing To Travel?

Are You Willing To Relocate?

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

Are You Legally Authorized to Work in the U.S.?
Have you ever worked in this facility?
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
Current Employee
Job Line
Other:

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 EVER been convicted of or pled guilty to ANY crime, entered a plea of nolo contendere, or received a deferred judgement, excluding minor traffic offenses and parking tickets?
Arrests or charges that have been expunged need not be disclosed.
If yes, give date, place and nature of each such conviction.

List ANY convictions, guilty pleas, please...

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?
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:
Vocational/Technical School
School:
    City:
   State:
1    2    3    4
Graduated?
Degree:
Other
School:
    City:
   State:
1    2    3    4
Graduated?
Degree:

PROFESSIONAL LICENSES AND REGISTRATIONS

Type of Profession: License #: Temp #:


State Date Issued(mm/dd/yyyy) Date Expires

Year Original License Issued: Has your Professional License ever been suspended?

If yes, 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