Horn Memorial Hospital


Secure Application for Employment
HR7940 Rev 07/02
Human Resources Department
701 East Second Street
Ida Grove, Iowa 51445
 It is the policy of this facility to provide equal opportunity to persons regardless of actual or perceived race,
color, religion, national origin, sex, age, disability, marital status, sexual orientation, gender identity,
political affiliation, or any other classification in accordance with federal, state and local statutes, regulations or ordinances.
http://www.hornmemorialhospital.org
email:  lorraine@hornmemorialhospital.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?

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
Full Time
 PRN
Part Time
 Temporary
Shift

 Weekend
Day
 Night
Evening
 Rotation
Salary Requirement
$
Are You Willing To Travel?

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, when?
If you drive for Horn Memorial Hospital you are required to have the appropriate current and unrestricted license. You will be required to furnish proof of your driving record as part of your application and may be required to release your driving record annually thereafter.

How did you learn about this position?
State Employment
       Commission
 Internet
Agency
 Ad
Job Listing
 School
Current Employee
Who? 		Relative
Who?
Other:

Are you able to perform the essential, job related functions of the position for which you are applying with or without reasonable accommodations?
Educational History
Type of School
 Name of School
City, State
 Check Last Year
Attended in School
Degree or Certificate
High School
 School:
    City:
   State:
Dates attended:
to
9   10   11   12
Graduated/GED?
Degree:
College
 School:
    City:
   State:
Dates attended:
to
1     2     3    4
Graduated?
Degree:
College
 School:
    City:
   State:
Dates attended:
to
1    2    3     4
Graduated? 		Degree:
Graduate
School
 School:
    City:
   State:
Dates attended:
to
1    2     3    4
Graduated? 		Degree:
Other
 School:
    City:
   State:
Dates attended:
to
1    2    3    4
Graduated? 		Degree:
Other
 School:
    City:
   State:
Dates attended:
to
1    2    3    4
Graduated? 		Degree:
List any professional licenses, registration or certification you possess
(Include only the last 4 digits of your Driver's License, if applicable)
Include Type, State Issued, Expiration Date and Number.
Indicate if any licenses have been revoked, suspended or placed on probation.
Also indicate if you are ineligible to become licensed or certified in your field. Please explain.
Clerical or other skills applicable to the position for which you are applying
Typing (WPM)
Proficient in Software: 
Business machines and/or equipment you can operate:
      
Other