Secure Application for Employment
HR7940 Rev 07/02
Human Resources Department
1604 Aylward Avenue
Ellsworth, Kansas 67439
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.                                                                                       

Please note that applications are in two sections. Your application is not complete and cannot be considered unless the Staff Survey is completed.

http://ecmc2ks.fasthealth.com

Date
This application can be active as long as legally required.
Last Name                                    First Name                                  Middle Initial
   
Are You At Least 16 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

Current Open Position(s) for Which You Are Applying



Salary Requirement
$

Are You Willing To Travel?



Are You Willing To Relocate?

Indicate all shifts that you would be available

Full Time
Part time (hrs/wk.)
PRN

8 Hr Shifts:
7AM-3:30
3:30-12AM
12AM-8:30
12 Hr. Shifts:
7AM-7PM
7PM-7AM

Weekend Holiday

Part time/PRN:
S M T W T F S
Times:

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?
How did you learn about this position?
Newspaper Ad
Online Job Board
Social Media
School
Current Employee:
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 other than a minor traffic violation?
If yes, please explain.
Conviction of a crime will not necessarily be a bar to employment.
No conviction or release from confinement will be considered after ten years.
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:

Summarize any special skills or training that is relevant to the position you are applying for.
SPECIAL SKILLS AND QUALIFICATIONS
LIST LICENSES/CERTIFICATIONS WHICH ARE REQUIRED FOR THIS POSITION
TYPE
REGISTRATION #
EXPIRATION DATE
Typing WPM, 10-Key  Medical Terminology  Microsoft Programs
Other, please list Are you licensed to work in Kansas? Yes No