Secure Application for Employment
Human Resources Department
3349 South Highway 181
Kenedy, Texas 78119
This organization complies with all federal, state and local equal Employment opportunity laws and guidelines.
http://www.okmh.org
email:
Date
PLEASE COMPLETE ALL ITEMS. ENTER N/A IF ITEM DOES NOT APPLY TO YOU
Last Name First Name Middle Initial
Date Available:
Home Phone
Cell Phone
Present Address
Present City
Present State
Present Zip Code
E-Mail Address
Current Open Position(s) for Which You Are Applying
Certified Medical Assistant
Certified Phlebotomist
Clinic Receptionist
Dietary Cook/Aide
General Application
General Application
Housekeeper/Environmental Services Technician
MT, MLT. or CLS PRN/ As needed.
Orthopedic Clinic Technician
Physical Therapist PRN
PRN Licensed Occupational Therapist
Registered Respiratory Therapist (RRT)
Registered Respiratory Therapist PRN
RN - Med-Surg
RN, Emergency Dept.
Certified Medical Assistant
Certified Phlebotomist
Clinic Receptionist
Dietary Cook/Aide
General Application
General Application
Housekeeper/Environmental Services Technician
MT, MLT. or CLS PRN/ As needed.
Orthopedic Clinic Technician
Physical Therapist PRN
PRN Licensed Occupational Therapist
Registered Respiratory Therapist (RRT)
Registered Respiratory Therapist PRN
RN - Med-Surg
RN, Emergency Dept.
Certified Medical Assistant
Certified Phlebotomist
Clinic Receptionist
Dietary Cook/Aide
General Application
General Application
Housekeeper/Environmental Services Technician
MT, MLT. or CLS PRN/ As needed.
Orthopedic Clinic Technician
Physical Therapist PRN
PRN Licensed Occupational Therapist
Registered Respiratory Therapist (RRT)
Registered Respiratory Therapist PRN
RN - Med-Surg
RN, Emergency Dept.
Type of Position
Per Diem
Pool
Full Time
PRN
Part Time
Temporary
Shift
Weekend
Day
Night
Evening
Rotation
Why Do You Choose Hospital Work?
What Prompted You to Apply Here for Employment?
Are you related to any current employee? Who and How?
Hobbies:
How did you learn about this position?
State Employment
Commission
Internet
Agency
Ad
Job Listing
School
Current Employee
Job Line
Other:
IN CASE OF EMERGENCY NOTIFY:
Name:
Relationship:
Have you been convicted of a felony within the last 10 years?
Yes
No
If so, what was the conviction?
Where?
City:
State:
Do you have any moving violations or accidents on your driving record?
Yes
No
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?
No
GED
Yes
Degree:
College
School:
City:
State:
1
2
3
4
Graduated?
n/a
Yes
No
Degree:
College
School:
City:
State:
1
2
3
4
Graduated?
n/a
Yes
No
Degree:
Graduate
School
School:
City:
State:
1
2
3
4
Graduated?
n/a
Yes
No
Degree:
Other
School:
City:
State:
1
2
3
4
Graduated?
n/a
Yes
No
Degree:
Other
School:
City:
State:
1
2
3
4
Graduated?
n/a
Yes
No
Degree:
List any professional licenses, registration or certification you possess
(Include 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)
PBX
Proficient in Software:
Business machines and/or equipment you can operate:
Other