Employment Application | Audubon County Memorial Hospital & Clinics

ACMH is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, sexual orientation, gender identity, marital status, national origin, disability, or veteran status or any other characteristic protected by state, federal, or local law.

This institution is an equal opportunity provider and employer.

If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov.

"*" indicates required fields

Personal Information

Name*

First Middle Last

Address*

Street Address City State ZIP Code

Email*

Phone*

List any other name(s) by which you have been known by previous employer(s) or educational institution(s):

Are you 18 or over?*

Yes

For applicants applying for a position which involves driving, do you have a current valid drivers license for the state of IA?*

Yes

Have you ever been excluded from providing patient care to those receiving Medicare or other federally funded health care programs?*

Yes

If yes, please explain

Do you have a record or founded child or dependent adult abuse?*

Yes

If yes, please explain

Have you ever been convicted of a crime in this state or any other state?*

Yes

If yes, please explain

Are you an honorary discharged veteran?*

Yes

Job Interests

Position Desired*

Available to Start

Alternate Position Desired:

Position

What shifts can you work?*

Days

Evenings

Nights

Holidays

What is your expected starting salary?*

List the name and relationship of any relative currently employed by this organization*

How did you hear about the position?*

Employment Agency

Job Posting

Indeed

Friend

Social Media (Facebook or LinkedIn)

Website

Radio

Other

Can you, if hired, submit verification of your legal right to work in the U.S.?*

Yes

If hired, you will be required to submit documents sufficient to establish employment authorization and identity in compliance with the Immigration Reform and Control Act of 1986.

Employment History

Are you presently employed?*

Yes

First Employer

Employer Name*

Your Position

Address*

Street Address City State ZIP Code

Employed From

Employed To

Description of Work Performed

Reason for leaving

Supervisor Name/Title

May we contact this employer?*

Yes

We will only contact the employer if a contingent offer is made.

Second Employer

Add a Second Employer?

Second Employer

Employer Name

Your Position

Address

Street Address City State ZIP Code

Employed From

Employed To

Description of Work Perfomed

Reason for leaving

Supervisor Name/Title

May we contact this employer?*

Yes

Third Employer

Add a Third Employer?

Third Employer

Employer Name

Your Position

Address

Street Address City State ZIP Code

Employed From*

Employed To*

Description of Work Performed

Reason for leaving

Supervisor Name/Title

May we contact this employer?*

Yes

Fourth Employer

Add a Fourth Employer?

Fourth Employer

Name

Your Position

Address

Street Address City State ZIP Code

Employed From

Employed To

Description of Work Performed

Reason for leaving

Supervisor Name/Title

May we contact this employer?*

Yes

Education Record

Name & Address of School

Degree/Diploma

Course of Study

Years Attended

Did you graduate?*

Yes

Second School

Add a Second School?

Name & Address of School

Degree/Diploma

Course of Study

Years Attended

Did you graduate?*

Yes

Third School

Add a Third School?

Name & Address of School

Degree/Diploma

Course of Study

Years Attended

Did you graduate?*

Yes

Fourth School

Add a Fourth School?

Name & Address of School

Degree/Diploma

Course of Study

Years Attended

Did you graduate?*

Yes

Additional Information

Professional License Information

If applicable, list all professional licensure information.

Professional Licensure

State Issued

Number

Expiration Date

Second License

Add a Second License?

Professional Licensure

State Issued

Number

Expiration Date

Third License

Add a Third License?

Professional Licensure

State Issued

Number

Expiration Date

Fourth License

Add a Fourth License?

Profession

State Issued

Number

Expiration Date

If applicable, list all professional registration/certification information.

Professional Certification

Number

Expiration Date

Second Organization/Profession

Add a Second Organization/Profession?

Professional Certification

Number

Expiration Date

Third Organization/Profession

Add a Third Organization/Profession?

Professional Certification

Number

Expiration Date

Fourth Organization/Profession

Add a Fourth Organization/Profession?

Professional Certification

Number

Expiration Date

If applicable, list any other professional credentials that you feel would relate to the position(s) for which you are applying (i.e. ACLS, BCLS, CPR).

Please state any additional information you believe would be important in considering your application:

Pre-Interview Questions

Why are you interested in working for Audubon County Memorial Hospital?*

What reasons do you have for leaving your current (or most recent) job?*

Based on what you know about the position we are recruiting for, what skills and experience do you have directly related to this position?*

What work accomplishment are you most proud of?*

Were you referred by a current ACMH employee?*

Yes

If Yes, please list the name(s) of the individual(s).

Employment References (must be professional work related references, 3 are required)

Give Name(s) of person(s) we may contact to verify your qualifications for the position

First Reference

Name*

Occupation

Organization

Relationship

Telephone Number*

Email*

Address

Second Reference

Name*

Occupation

Organization

Relationship

Email*

Telephone Number*

Address

Third Reference

Name*

Occupation

Organization

Relationship

Telephone Number*

Email*

Address

To the best of my knowledge, all of the information I have submitted on this application is true and complete. I understand that any omission or falsification of information will be sufficient cause for disqualification from further consideration for employment or for dismissal. I voluntarily give this organization the right to make a thorough investigation of my personal or past employment history and education, as well as to perform criminal history, dependent adult and child abuse checks. I agree to cooperate in such investigation and authorize any former employer, person, firm or corporation to give this organization any information they may have regarding me. In consideration of this organization's review of this application, I release this organization and all providers of information from any liability as a result of furnishing and receiving this information. I understand that any offers of employment are contingent on successful completion of the post-offer exam and background checks. I understand employment at this organization is "at will," which means employment may be terminated by the employee, or by this organization at any time, with or without cause. I further understand employee benefits, terms and conditions of employment and the policies, procedures and work rules of the organization may be determined, changed and modified from time to time by this organization without limitation or agreement. I also understand any employment handbooks or manuals that may be distributed to me by this organization shall not be construed as a contract. I hereby agree that if I become employed by this organization, I consent to the release of all my future educational records involving classes, coursework, seminars and all other educational programs in which I am enrolled or attend and for which a portion or all of the enrollment fee, or tuition will be paid by this organization to an accredited higher education institution. This consent will be effective on my date of employment and until I specifically revoke it in a signed and dated writing delivered to the higher education institution.

I agree to all terms and conditions*

I agree

Signature*

First Last

Attach Resume

Accepted file types: pdf, doc, docx, txt, rtf, Max. file size: 128 MB.

Captcha