Secure Application for Employment
Human Resources Department
711 Onyx Street
Kemmerer, Wyoming 83101
All forms of communication will be transmitted via email.

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.southlincolnmedical.com
email:  Sraver@southlincolnmedical.com
Date
This application can be active as long as legally required.
Last Name                                    First Name                                  Middle Initial
   
Last 4 Digits of
Social Security Number

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


Salary Requirement
$
Are You Willing To Travel?

Are You Willing To Relocate?

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 for SLMC before?
If yes, please provide dates and position. 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
Which employee?
Job Line
Other:

Can you perform the essential functions of the job as described on the position description with or without a reasonable accommodation?

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.


Has your license ever been suspended or revoked, or are you currently involved in any proceedings that could affect your license or certification?
If yes, please give date, location, and disposition of your case.
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