Coffeyville Regional Medical Center

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

Cell Phone Or Home 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?
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 

 


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