Secure Application for Employment
Human Resources Department
373 East Tenth Avenue
Springfield, Colorado 81073

http://www.sechosp.org
email: 
Date

Last Name                                    First Name                                  Middle Initial
   
Are You At Least 18 Years Old?

Cell Phone

Alternate Phone

Address

City

State

Zip Code

E-Mail Address

Current Open Position(s) for Which You Are Applying


Type of Position
Full Time
PRN
Part Time
Weekend Only
Any
Shift Available
Day
Night
Evening
Any Shift
Days you can work:
Sunday Thursday
Monday Friday
Tuesday Saturday
Wednesday
Date Available to Start

Do you have the legal right to work in the United States in the job for which you are applying?
(Proof of eligibility to work in the United States)

Are you a previous employee of Southeast Colorado Hospital District?
If yes, month and year employed:
Under what name:
Were you referred by a current employee?
If yes, employee name:
The following information is requested to assist us in assessing the effectiveness of our recruiting activities. Your cooperation is appreciated. How did you hear about this job? PLEASE CHECK ONLY ONE:
Local Newspaper
Job Posting
(Name)
TV/Radio Announcement
Job Fair/Career Day
(Name)
Direct Mail
School
(Name)
Walk-In
External Recruiting Agency
(Name)
  Professional Association/Conference
(Name)
  Professional/Trade Journal of Magazine
(Name)
  Website
(Name)
  Other (Name)

Are you related to a current employee within the department you are applying?
If yes, list names and relationships:
(Includes spouses, children, parents, in-laws, siblings, legal dependents, members of the same residence, or any person who fulfills an immediate family role for you.)
Have you been subject of any adverse action(s) by any duty authorized sanctioning or disciplinary agency for either conduct based or performance based actions?
If yes, explain:

Have you ever been excluded, suspended, or debarred from, or otherwise declared ineligible to provide services in the Medicare or Medicaid programs, or any other federally-funded health care 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:
Other
School:
    City:
   State:
1    2    3    4
Graduated?
Degree:
List any professional licenses, registration or certification you possess
Include Name of License/Registration/Certification, State, Number, Year Issued, Current (Yes/No), and Expiration Date.


If currently eligible for license, registration, or certification please indicate states and date here:

Has your license, registration, or certification in this state or another state been suspended, limited, revoked, or subjected to disciplinary action:
If yes, please explain:

Additional Certifications:
CPR: Expiration Date:
BLS: Expiration Date:
ACLS: Expiration Date:
Please list any professional organization to which you subscribe or are a member.