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Thank you for your interest in joining the Coffey Health System team.

For which position are you applying?

For which position are you applying?*

How did you learn of this job opening?*

Name of referring CHS employee

Are you able to work:*

Indicate your preferred place of employment. Mark all that apply.*

Coffey County Hospital (Burlington)

The Meadows (Burlington)

Physician Clinics (four locations)

Personal Information

First Name*

Middle Name

Last Name*

Maiden (optional)

Email*

Last 4 digits of social security number*

Race / Ethnicity (Optional)

Gender*

Female

Male

Ethnic Identify

Address

Street Address*

City*

State / Province / Region*

Zip / Postal Code*

Contact Information

Phone Number*

In emergency, notify*

General Information

Are you over 18 years of age?*

Yes

If no, state birth date

Have you ever been employed by Coffey Health System?*

Yes

If yes, give date:

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If yes, under what name?

Reason separated

Do you have any relatives employed by Coffey Health System?

Yes

Are you currently employed?*

Yes

If yes, may we contact your present employer?

Yes

Do you have a current and valid Kansas state drivers license?*

Yes

Have you been convicted of a crime which resulted in being listed by a state or federal agency as disbarred, excluded or otherwise ineligible?*

Yes

Have you ever been convicted of a crime other than a traffic violation?*

Yes

If yes to either above question, please explain. A conviction will not necessarily bar you from employment and will be evaluated on its own merit.

Have you ever been discharged from a job?*

Yes

If yes, explain.

Do you have the legal right to live and work in the United States?*

Yes

If non-citizen, indicate visa type, number and expiration date.

Education

High School Name, City, and State

Diploma / Degree

Undergraduate / College

Undergraduate School Name, City, and State

Course of study

Degree completed

Graduate / Professional

Graduate School Name. City, and State

Graduate Diploma / Degree

Additional Information

Other Qualifiations, Professional Registration or Licensure

Specialized Skills

Spreadsheet

Word Processing

Equipment you've operated

Employment Experience

Employer #1 (starting with most recent)

Position/Job Title

Employer #1 Address (Street, City, State, Zip)

Employer #1 Telephone

Employer #1 Supervisor Name

Employer #1 Start Date

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Employer #1 End Date

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Employer #1 Starting Hourly Wage / Salary

Employer #1 Final Hourly Wage / Salary

Employer #1 Work Performed

Employer #1 Reason for Leaving

Employer #2

Position/Job Title Employer 2

Employer #2 Address (Street, City, State, Zip)

Employer #2 Telephone

Employer #2 Supervisor Name

Employer #2 Start Date

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Employer #2 End Date

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Employer #2 Starting Hourly Wage / Salary

Employer #2 Final Hourly Wage / Salary

Employer #2 Work Performed

Employer #2 Reason for Leaving

Employer #3

Position/Job Title Employer 3

Employer #3 Address (Street, City, State, Zip)

Employer #3 Telephone

Employer #3 Supervisor Name

Employer #3 Start Date

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Employer #3 End Date

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Employer #3 Starting Hourly Wage / Salary

Employer #3 Final Hourly Wage / Salary

Employer #3 Work Performed

Employer #3 Reason for Leaving

Activities

List professional, trade, business or civic activities and offices held.

Professional References

Reference #1 Name

Reference #1 Occupation

Reference #1 Address

Reference #1 Telephone

Reference #2 Name

Reference #2 Occupation

Reference #2 Address

Reference #2 Telephone

Applicant's Statement

The facts set forth in my application for employment are true and complete. False statements, answers or omissions on this application shall be sufficient cause for non-consideration for employment or for dismissal after employment. I also recognize that my employment is based on receipt of satisfactory information from former employers and references, and my ability to pass pre-employment screenings. I herein authorize the administration for this institution to investigate, without liability, the information supplied by me in this application for employment including academic, occupational, health, police, and governmental records. I also authorize listed employers and references, without liability, to make full response to any inquiries by the administration of this institution in connection with this application for employment. Further, if employed, I agree to work the hours, days and shifts as scheduled. I will share weekend and holiday coverage. I will work in another department if requested to do so. I understand and agree that the terms, conditions, compensations, benefits, hours, schedule, and duration of my employment (whether set forth in the Employee Handbook or not) may be determined, changed or modified from the time at the will of my employer without limitation or condition. I FURTHER CERTIFY THAT I HAVE READ THE FOREGOING PARAGRAPH AND KNOWINGLY MAKE THIS AUTHORIZATION BY SETTING FORTH MY SIGNATURE.

This application for employment shall be considered active for a period of time not to exceed 90 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

In the event of employment, I understand that false or misleading information given in my application or interview may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Agree / Disagree*

Yes

(By checking "I AGREE", I verify the above "APPLICATION'S STATEMENT" is true.)

Signature*

Date

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Have you been excluded from participation in Medicaid/Medicare because of fraud conviction?*

Yes