Secure Application for Employment
	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.stantoncountyhospital.com/

Date

This Application can be active as long as legally required.

Last Name * First Name * Middle Initial * *

Are You At Least 18 Years Old? Yes No

Social Security Number without dashes or spaces (secure)

Primary And Secondary Phone * * *

Present Address * *

Present City * *

Present State * *

Present Zip Code * *

E-Mail Address

Previous Address

Previous City

Previous State

Previous Zip Code

Current Open Position for Which You Are Applying for Certified Physical Therapy Assistant Are you currently credentialed for the position for which you are applying?   Yes No

Type of Position Full Time Part Time Casual Part Time Temporary

Shift   Weekend Day Night Evening Rotation

Salary Requirement $

Are You Willing To Travel? Yes No

Are You Willing To Relocate? Yes No

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?   Yes No

If overtime work is required periodically, does this pose a problem for you?   Yes No

Date Available For Work

Are You Legally Authorized to Work in the U.S.?  Yes No

Have you ever worked for Stanton County Hospital?   Yes No

If yes, what year did you leave?

Are you related to another facility employee?   Yes No

How did you learn about this position? College Placement Office State Employment Service Employment Advertisement:    Employment Agency:    Other:

Are you able to perform the essential, job related functions of the position for which you are applying with or without reasonable accommodations?   Yes No   Describe any accommodations necessary:   Have you been convicted of a crime and/or released from confinement following a conviction for any criminal offense?   Yes No   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?   Yes No If yes, give date, place and nature of each such conviction: 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?   Yes No

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) Proficient in Software Business machines and /or equipment you can operate: Other  E-mail, Internet, or Outlook Microsoft Applications Excel, Word, PowerPoint, Access and Publisher List Basic Computer Skills