Secure Application for Employment
HR7940 Rev 07/02
Human Resources Department
1501 E. 3rd Street
Delta, Colorado 81416
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.deltahospital.org
email:  personnel@deltahospital.org
Date
This application is active for 180 days or 6 months.
Last Name                                    First Name                                  Middle Initial
   
Are You At Least 18 Years Old?

Social Security Number (secure)

Home Phone And Cell Phone

Present Address

Present City

Present State

Present Zip Code

E-Mail Address

Current Open Position(s) for Which You Are Applying



Type of Position
Full Time
PRN
Part Time
Shift

Day
Night
Evening

Are You Legally Authorized to Work in the U.S.?
Have you ever been employed with Delta County Memorial Hospital before?
If yes, please provide department/position, name used and dates employeed. Do you have any relatives currently employeed at DCMH?
If yes, please provide name of relative, department they work in and your relationship.

How did you learn about this position?
Delta County
       Independent

Hospital Website
High Country Shopper
The Daily Sentinel
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 a crime or violation other than a minor traffic infraction?
If yes, please make sure you complete the addendum at the end of this application.

Have you ever been discharged from any employment or asked to resign?
If yes, please explain:

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:
Other
School:
    City:
   State:
1    2    3    4
Graduated?
Degree:
Other
School:
    City:
   State:
1    2    3    4
Graduated?
Degree:
Medical Terminology course?
Typing Speed WPM
Number of Errors
Transcription
Transcription Speed WPM
Bookkeeping
Data Entry
License and/or Certification
Are you currently registered, licensed or certified to practice in the state of Colorado?
Profession
Number
Expiration Date
Have you ever had a license or registry suspended or revoked?
If yes, please explain: