Employment Application

Johnson Memorial Health Services (JMHS) is an equal employment opportunity employer dedicated to a policy of nondiscrimination in employment based upon an individual's race, color, creed, religion, national origin, sex, marital status, status with regard to public assistance, familial status, disability, sexual orientation, age, or other characteristics protected by law. In reading and answering the following questions, please keep in mind that none of the questions are intended to imply any limitations, illegal preferences, or discrimination based upon any non-job-related information. This application will be given consideration, but its receipt does not imply that the applicant will be interviewed or employed. If you need an accommodation to participate in the application process, please contact Human Resources at (320) 312-2113.

Today's Date

Position Applying For

Date Available to Start Work

Name

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Daytime Phone

Evening Phone

Cell Phone

Email

Have you ever applied for a job with this company in the past?

YesNo

Please give the date of application and the position for which you applied. State your name at that time, if different from present name.

Have you ever been employed by this company in the past?

YesNo

Please give dates of employment, positions held, and state your name while employed if different from present name.

If hired, will you be able to work during the normal days and hours required for the position(s) for which you are applying?

YesNo

Please explain.

Do you have any commitments to another employer that might affect your availability for employment with our company? (i.e. on layoff)

YesNo

Please explain.

If hired, can you furnish proof that you are at least 18 years of age and that you are eligible to work in the United States?

YesNo

Please explain.

Do you now, or will you in the future, require Johnson Memorial Health Services to sponsor an employment visa for your continued employment?

YesNo

Are you able to perform the tasks listed on the enclosed/attached job description with or without an accommodation?

YesNo

What High School did you attend?

Did you graduate from high school?

YesNo

What was your highest grade completed?

9th Grade10th Grade11th Grade

What additional education have you received? (check all that apply)

Technical, Vocational or Business SchoolMilitary TrainingCollege or University

Did you graduate?

YesNo

List your major course of study and any Degree, Diploma or Certificate received.

Explain the Military Training that you received.

Did you graduate?

YesNo

List your major course of study and any Degree, Diploma or Certificate received.

Please list any JOB RELATED professional or trade seminars, classes or workshops attended.

Please list any JOB RELATED special skills or abilities, certifications, licenses, equipment qualified to operate, computer systems or hardware/software knowledge, or any information you believe would be of value in considering you for employment.

Upload Resume if desired

Are you currently employed?

YesNo

Current Employer Name

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Your Job Title and Duties

Current Wages (hourly)

Start date of employment

Supervisor's Name and Job Title

Supervisor's Phone Number

May we contact?

YesNo

Past Employer - Company Name

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Your Job Title and Duties

Wages (hourly)

Dates of Employment

Supervisor's Name and Job Title

Supervisor's Phone Number

Reason for Leaving

Do you have additional past employers?

YesNo

Past Employer - Company Name

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Your Job Title and Duties

Wages (hourly)

Dates of Employment

Supervisor's Name and Job Title

Supervisor's Phone Number

Reason for Leaving

Do you have an additional past employer?

YesNo

Past Employer - Company Name

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Your Job Title and Duties

Wages (hourly)

Dates of Employment

Supervisor's Name and Job Title

Supervisor's Phone Number

Reason for Leaving

Please account for any time you were not employed after leaving school in the past ten years (You need not list any unemployment periods of one month or less).

(1) Reference Name

Relationship

Phone

(2) Reference Name

Relationship

Phone

(3) Reference Name

Relationship

Phone

Some people gain job-related experience in positions other than as an employee. (Please omit any activities, honors, memberships or other items that tend to identify your race, sex, national origin, age, disability or other personal traits that you prefer not to disclose.)

Please list and describe any paid or unpaid activities, honors, experience, or training that might aid you in performing the job(s) for which you have applied, and have not been listed previously in this application.

Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. Applicants and employees during their employment are treated without regard to their race, color, creed, religion, national origin, sex, marital status, status with regard to public assistance, familial status, disability, sexual orientation, age, or any other legally protected status. Johnson Memorial Health Services is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, the employer invites applicants and employees to voluntarily self-identify their race or ethnicity. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.

How were you referred to our company?

Job ServiceNewspaper AdvertisementPrivate Employment AgencyA relative or friend employed by this companyOther

Please explain.

Check One

MaleFemale

Check any that apply

Vietnam Era VeteranDisabled PersonDisabled Veteran

Check One

WhiteBlack or African American (Not Hispanic or Latino)Hispanic or LatinoNative Hawaiian or other Pacific Islander (Not Hispanic or Latino)American Indian/Alaskan NativeTwo or more races (Not Hispanic or Latino)

I promise that the information provided in this employment application (and accompanying resume, if any) is true and complete. *

I understand that any false information or significant omissions may disqualify me from further consideration for employment, and may be justification for my dismissal from employment by Johnson Memorial Health Services if discovered at a later date. I agree to immediately notify Johnson Memorial Health Services if I should be convicted of a felony, or be charged with any crime while my job application is pending, or during my period of employment, if hired.I agree

I authorize any person, school, current employer (except as previously noted), past employer(s), government or investigative agencies, and other organizations that may be named in this application form (and accompanying resume, if any) to provide the company with relevant information and opinion that may be useful to Johnson Memorial Health Services in making a hiring decision, and I release such persons and organizations from any legal liability in making such statements.I agree

If offered a job that requires it, I give permission for a background check, drug test and a job-related physical evaluation, and I consent to the release to the Company of any medical information they deem necessary in assessing my capability to perform the essential functions of the work for which I am applying (with or without a reasonable accommodation).I agree

I understand that, if hired, I may not hold other employment, nor engage in consulting, sales, investments or other activities that may create a conflict of interest with Johnson Memorial Health Services.I agree

I understand that if employed and my employment is terminated by Johnson Memorial Health Services for dishonesty, breach of trust, or any criminal acts, the authorities may be notified and I may be criminally prosecuted.I agree

I understand that this application does not, by itself, create a contract of employment. I understand and agree that, if hired, my employment is for no definite period of time, and may be terminated at any time. I understand that only the President of Johnson Memorial Health Services is authorized to change any of the terms of employment and that any changes must be specific and in writing.I agree

Online Application

PERSONAL DATA

GENERAL INFORMATION

EDUCATIONAL DATA

EMPLOYMENT HISTORY - complete even if including a resume

REFERENCES - please provide 3 references

OTHER JOB RELATED EXPERIENCE

HEALTH SERVICES DATA

AGREEMENT - Please read carefully and check each paragraph before submitting.

Verification