Online Application - Minneola Healthcare

HUMAN RESOURCE DEPARTMENT
P. O. Box 127
212 Main
Minneola, KS 67865
Phone: 620-885-4264
Fax: 620-885-4632
An Equal Opportunity Employer

Facility Applying For

Hospital

Clinic

LTCU

Position

Date Available For Work

Date of Application

Desired Salary

Available Part Time or Full Time?

Full Time

Part Time

Part Time Days Availability

Part Time Days Time Availability

8 Hour Shift Availability

Days

Evenings

Nights

NA

12 Hour Shift Availability

7am - 7pm

7pm - 7am

NA

How did you learn of our organization?

Please indicate which ad you saw or other referral reference

Personal Data

Last Name

First Name

Middle Initial

Social Security #

Mailing and Street Address

City, State

Zip Code

Home Phone

Cell Phone

Email Address

Are you eligible to work in the United States?

IF HIRED, YOU WILL BE REQUIRED TO PROVIDE DOCUMENTATION VERIFYING CITIZENSHIP OR
ELIGIBILITY TO WORK IN THE UNITED STATES

Background Information

Are you 16 years of age or older?

Yes

No

Have you ever been convicted of a criminal offense, other than minor traffic offenses?

Yes

No

If, Yes please explain

Conviction is not an automatic elimination from employment. Each case is considered individually; however, failure to identify a conviction is cause for automatic ineligibility for hire or dismissal.

3. Have you previously been employed by a Minneola Healthcare facility?

Yes

No

If YES, please list the facility, date, and position held

Educational Background

High School Attended Name and Address

Did you graduate?

Yes

No

Level of Achievement

Diploma

GED

Names and Addresses of Technical, Vocational, Business or Military Training Schools

Did you graduate?

Yes

No

If no, total credits

Did you receive Degrees, Diplomas, Certificates or the like?

Degree

Diploma

Certificate

Date received

What was the focus, such as Major or Minor

Name and Address of College or University

Did you graduate?

Yes

No

If no, total credits

What was your degree?

Date received

What was your major and or minor?

Name and Address of Graduate School

Did you graduate?

Yes

No

If no, total credits

What was your degree?

Date received

What was your major and or minor?

Summarize any special skills or training that is relevant to the position you are applying for

List special skills and qualifications related Licenses/Certifications which are required for this position by type, registration # and expiration date

Other advanced skills

Please explain special skills marked above

Are you licensed to work in Kansas?

Yes

No

Employment Record
Starting with your PRESENT or MOST RECENT employer, please list ALL jobs you have had including military experience for at least the past five (5) years. DO NOT omit any work experience. If you need more room, please email a Word Document with additional employer information to humanresources@minneolahealthcare.com. PLEASE COMPLETE THIS SECTION EVEN IF PROVIDING A RESUME.

Name of Present or Most Recent Employer

Employer's Address

City, State

Zip Code

Start Date

End Date

Part time or full time?

Part time

Full time

Part time hours?

Job title

Reason(s) for leaving

May we contact this employer?

Yes

No

If yes, supervisor's name

Business phone

Your name while working here

Salary amount, hourly, weekly or yearly

Name of Previous Employer 2

Employer's Address

City, State

Zip Code

Start Date

End Date

Part time or full time?

Part time

Full time

Part time hours?

Job title

Reason(s) for leaving

May we contact this employer?

Yes

No

If yes, supervisor's name

Business phone

Your name while working here

Salary amount, hourly, weekly or yearly

Name of Previous Employer 3

Employer's Address

City, State

Zip Code

Start Date

End Date

Part time or full time?

Part time

Full time

Part time hours?

Job title

Reason(s) for leaving

May we contact this employer?

Yes

No

If yes, supervisor's name

Business phone

Your name while working here

Salary amount, hourly, weekly or yearly

Name of Previous Employer 4

Employer's Address

City, State

Zip Code

Start Date

End Date

Part time or full time?

Part time

Full time

Part time hours?

Job title

Reason(s) for leaving

May we contact this employer?

Yes

No

If yes, supervisor's name

Business phone

Your name while working here

Salary amount, hourly, weekly or yearly

Name of Previous Employer 5

Employer's Address

City, State

Zip Code

Start Date

End Date

Part time or full time?

Part time

Full time

Part time hours?

Job title

Reason(s) for leaving

May we contact this employer?

Yes

No

If yes, supervisor's name

Business phone

Your name while working here

Salary amount, hourly, weekly or yearly

PROFESSIONAL CERTIFICATION/LICENSES

License/Registration #

Profession

Expiration Date

License/Registration #

Profession

Expiration Date

Are you CPR/BLS certified?

Yes

No

Date

Are you ACLS certified?

Yes

No

Date

Any other certifications?

Yes

No

What other certifications?

Date

References
List individuals who are familiar with your work and educational qualifications: Friends and family are not accepted.

Name

Address

City, State

Zip Code

Phone

Relationship

Name

Address

City, State

Zip Code

Phone

Relationship

This institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, 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 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 along with any future physical examinations, which could include a drug screening, 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 and that I will be subject to a probationary period.

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.

Typing Your Name Below and Submiting This Form Confirms Your Agreement As Signature of Applicant

Date of Application