Secure Application for Employment
Human Resources Department
1201 Highway 71 South
Hot Springs, South Dakota 57747
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.frhssd.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?

Social Security Number (secure)

Cell Phone

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
Full Time
PRN
Part Time
Temporary
Shift Available
Day
Weekend
Evening
Night

Rotation
Salary Requirement
$
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. without sponsorship?
Have you ever worked at FRHS?
If yes, when? Are you related to another facility employee or Board Member?
If yes, who?
How did you learn about this position?
State Employment Website
FRHS Website
Current Employee - Name
Indeed
Facebook
Organic
Radio
Newspaper
Flyer
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 been convicted of a crime and/or released from confinement following a conviction for any criminal offense?
Arrests or charges that have been expunged need not be disclosed.
If yes, give date, place and nature of each such conviction.

Are you presently charged with any violation of the law?
If yes, give date, place and nature of each such event:

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:
List any professional licenses, registration or certification you possess
Include Type, State Issued, Expiration Date and Number.
Indicate if any licenses have been revoked, suspended or placed on probation.

Clerical or other skills applicable to the position for which you are applying

Proficient in Software:

Business machines and/or equipment you can operate:
      
EMR System
Name(s)
Other