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Secure Application for Employment
HR7940 Rev 07/02
Human Resources Department
6th Avenue and Franklin Street
Red Cloud, Nebraska 68970
 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.websterhospital.org/
email:  agriffin@websterhospital.org
 Date First Viewed
 This application can be active as long as legally required.
Last Name, First Name MI
 
Are You At Least 18 Years Old?
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
Position #1:
Position #2:
Position #3:

Type of Position
Full Time
 		PRN
Part Time
Shift

Day
 		Night

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 for WCCH?
Please provide position and dates of employment.
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:

Are you able to perform the essential, job related functions of the position for which you are applying with or without accommodations?
Describe any accommodations necessary:
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/
GED

9   10   11   12
Graduated/GED?

College

1    2     3    4
Graduated?

College

1   2    3     4
Graduated?

Graduate
School

1    2     3    4
Graduated?

Other

1    2    3    4
Graduated?

Other

1    2    3    4
Graduated?


List any professional licenses, registration or certification you possess
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 


Work History Application for Employment
HR7940 Rev 07/02





From
Mo.

 Yr.
To
Mo.

 Yr.
Company

 Phone No.

Immediate Supervisor
Salary
$
Address
May we contact them?

 Name while employed
Job Title

 Type of Position:
# Hrs /Week: 		Reason For Leaving
Nature of Duties





From
Mo.

 Yr.
To
Mo.

 Yr.
Company

 Phone No.

Immediate Supervisor
Salary
$
Address
Name while employed
Job Title

 Type of Position:
# Hrs/Week: 		Reason For Leaving
Nature of Duties






From
Mo.

 Yr.
To
Mo.

 Yr.
Company

 Phone No.

Immediate Supervisor
Salary
$
Address
Name while employed
Job Title

 Type of Position:
# Hrs/Week: 		Reason For Leaving
Nature of Duties






From
Mo.

 Yr.
To
Mo.

 Yr.
Company

 Phone No.

Immediate Supervisor
Salary
$
Address
Name while employed
Job Title

 Type of Position:
# Hrs/Week: 		Reason For Leaving
Nature of Duties
Professional References (Other than Relatives) Give references who have good knowledge of your work.
Name
Position
Address (Include City/State)
Phone - Work/Home
 Number of
Years known





















Please Review and Acknowledge That You Understand The Following.
In making application for employment:
* I certify that the information in this application is true and complete for all practical purposes.  It may be verified by the facility or any affiliate.  Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the facility or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.

* I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable.  If such an investigative report is made, I understand that I will receive notice that such a report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.

* I UNDERSTAND AND AGREE THAT ANY EMPLOYEE HANDBOOK WHICH I MAY RECEIVE WILL NOT  CONSTITUTE AN EMPLOYMENT CONTRACT, BUT  WILL BE MERELY A GRATUITOUS STATEMENT OF  FACILITY POLICIES.

* I understand that the facility reserves the right to require its employees to submit to blood tests or urinalyses for alcohol or drug screens, or to allow inspection of bags (including purses or briefcases) or parcels brought into  or taken out of the facility.  I understand that refusal to  submit to a urinalysis or blood test, when requested to  do so, may result in termination of my employment.

* Compliance with this facility's Substance Abuse Policy is  a condition of employment.  This hospital requires that  every newly hired employee be free of alcohol or drug  abuse.  Each offer of employment is contingent upon  successfully completing a urinalysis test/screen for  alcohol and drugs in accordance with facility policy. Continued employment is also contingent upon  compliance with the hospital's Alcohol and Drug Abuse Policy.

*I UNDERSTAND AND AGREE THAT IF I AM OFFERED  EMPLOYMENT BY THE FACILITY, MY EMPLOYMENT  WILL BE FOR NO DEFINITE TERM AND THAT EITHER  I, OR THE FACILITY WILL HAVE THE RIGHT TO  TERMINATE THE EMPLOYMENT RELATIONSHIP AT  ANY TIME, WITH OR WITHOUT CAUSE, AND WITH  OR WITHOUT NOTICE,  I ALSO UNDERSTAND THAT THIS STATUS CAN ONLY BE ALTERED BY A WRITTEN CONTRACT OF EMPLOYMENT WHICH IS SPECIFIC AS TO ALL MATERIAL TERMS AND IS  SIGNED BY ME AND THE ADMINISTRATOR OF THE FACILITY.

Release:
  I hereby authorize any prior employers to provide such  information concerning my employment with them as  may be requested, and also authorize the  Registrar/Placement Office of all educational institutions  attended to release an official copy of my transcript and,  if available, faculty appraisals.  I also authorize any  appropriate licensing board to release full information  concerning my licensure status and my licensure history.

This institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, Vietnam era veteran status, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.

I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I consent to take the physical examination, and such future physical examinations as may be required by this institution at such times and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physical examination which relates to the essential duties I would be required to perform.

I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.

If employed, I will be required to complete an Employment Verification Form (I-9), and within three days show satisfactory evidence of identity and eligibility for employment.
I agree that I will settle any and all claims, disputes or controversies arising out of or relating to my application for employment, employment or termination of employment with the employer exclusively by final and binding arbitration and before a neutral Arbitrator and in accordance with the rules and procedures for employment disputes adopted by the employer.  Such claims shall include those that could be brought in a court of law under any applicable federal, state or local statutory or common law, such as the Age Discrimination in Employment Act, Title VII of the Civil Rights Act of 1964, as amended, including the amendments of the Civil Rights Act of 1991, the Americans with Disabilities Act, the Family and Medical Leave Act, state civil rights acts, the law of contract and the law of tort.
I have read and understand
these conditions of employment.
Applicant's full name

 Date Prepared





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