Secure Application for Employment
HR7940 Rev 07/02
Human Resources Department
535 South Freeborn
Marion, KS 66861
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.slhmarion.org
email:  brinkerhoff@ubmc.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?

Social Security Number (secure)

Home Phone And Cell 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 in name of the desired position:  


Type of Position
Per Diem
Pool
Full Time
PRN
Part Time
Temporary
Shift

Weekend
Day
Night
Evening
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.?
Have you ever worked in this or any other facility?
If yes, what facility? Are you related to another facility employee?
How did you learn about this position?
State Employment
         Commission

Internet
Agency
Ad
Job Listing
School
Current Employee
Job Line
Other:


Have you ever been convicted of a misdemeanor or felony offense? (A conviction of a crime will not necessarily be a bar to employment.
Factors such as age at the time of the offense, type of offense, remoteness of the offense in time, and rehabilitation will be taken into
account in determining effect of suitability for employment).

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 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