Secure Application for Employment
Human Resources Department
1700 Old Lebanon Road
Campbellsville, Kentucky 42718
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.trhosp.org
email:  knmarshall@trhosp.org
Date

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

Last 4 Digits of
Social Security Number

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 of Position
Full Time
PRN
Part Time
Temporary
Shift Available

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 or Board Member?
Are you willing to work weekends? Are you willing to work holidays? Other names by which you may have been identified in employment records:
How did you learn about this position?
State Employment
         Commission
Internet
Agency
Ad
Job Listing
School
Current Employee
Other:
Rerferred by::

Have you ever been discharged or requested to resign from a position?
If yes, give date(s) and explain:

Have you been convicted of a crime (felony or misdemeanor) and/or released from confinement following a conviction for any criminal offense?
Arrests or charges that have been expunged need not be disclosed.
If yes, give date, place and nature of each such conviction.

Are you presently charged with any violation of the law?
If yes, give date, place and nature of each such event:

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?
If yes, give date(s) and explain:

Have you ever served in the U.S. Armed Forces?
If yes, what branch?
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             Medical Terminology
Proficient in Software: 
Business machines and/or equipment you can operate:
      
Other