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.

NOTE: Newly hired ACMH employees must show proof of full COVID-19 vaccination or receive at least one dose of the two-dose COVID-19 vaccines (Pfizer or Moderna) or have received the single dose of the Johnson & Johnson COVID-19 vaccine before they can begin work. Newly hired employees will be required to receive the second dose within three or four weeks of the initial vaccine depending on the vaccine protocol for that particular vaccine (Pfizer or Moderna). Reasonable accommodations may be available for individuals who are granted an exemption due to religious or medical reasons.

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
- No
For applicants applying for a position which involves driving, do you have a current valid drivers license for the state of IA?*
- Yes
- No
Have you ever been excluded from providing patient care to those receiving Medicare or other federally funded health care programs?*
- Yes
- No
If yes, please explain
Do you have a record or founded child or dependent adult abuse?*
- Yes
- No
If yes, please explain
Have you ever been convicted of a crime in this state or any other state?*
- Yes
- No
If yes, please explain
Are you an honorary discharged veteran?*
- Yes
- No
Job Interests
Position Desired*
Available to Start
Alternate Position Desired:
Position
- Full-time
- Part-time
- Contingent
- Temp
- Summer
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
- Advertisement
- Radio
- Other
Can you, if hired, submit verification of your legal right to work in the U.S.?*
- Yes
- No
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
- No
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
- No
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
- No
Third Employer
- Add a Third Employer?
Third Employer
Employer Name
Your Position
Address
Street Address City State ZIP Code
Employed From*
MM slash DD slash YYYY
Employed To*
MM slash DD slash YYYY
Description of Work Performed
Reason for leaving
Supervisor Name/Title
May we contact this employer?*
- Yes
- No
Fourth Employer
- Add a Fourth Employer?
Fourth Employer
Name
Your Position
Address
Street Address City State ZIP Code
Employed From
MM slash DD slash YYYY
Employed To
MM slash DD slash YYYY
Description of Work Performed
Reason for leaving
Supervisor Name/Title
May we contact this employer?*
- Yes
- No
Education Record
Name & Address of School
Degree/Diploma
Course of Study
Years Attended
Did you graduate?*
- Yes
- No
Second School
- Add a Second School?
Name & Address of School
Degree/Diploma
Course of Study
Years Attended
Did you graduate?*
- Yes
- No
Third School
- Add a Third School?
Name & Address of School
Degree/Diploma
Course of Study
Years Attended
Did you graduate?*
- Yes
- No
Fourth School
- Add a Fourth School?
Name & Address of School
Degree/Diploma
Course of Study
Years Attended
Did you graduate?*
- Yes
- No
Additional Information
Professional License Information
If applicable, list all professional licensure information.
Professional Licensure
State Issued
Number
Expiration Date
MM slash DD slash YYYY
Second License
- Add a Second License?
Professional Licensure
Number
State Issued
Expiration Date
MM slash DD slash YYYY
Third License
- Add a Third License?
Professional Licensure
State Issued
Expiration Date
MM slash DD slash YYYY
Number
Fourth License
- Add a Fourth License?
Profession
State Issued
Number
Expiration Date
MM slash DD slash YYYY
If applicable, list all professional registration/certification information.
Professional Certification
Number
Expiration Date
MM slash DD slash YYYY
Second Organization/Profession
- Add a Second Organization/Profession?
Professional Certification
Number
Expiration Date
MM slash DD slash YYYY
Third Organization/Profession
- Add a Third Organization/Profession?
Professional Certification
Number
Expiration Date
MM slash DD slash YYYY
Fourth Organization/Profession
- Add a Fourth Organization/Profession?
Professional Certification
Number
Expiration Date
MM slash DD slash YYYY
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
- No
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.
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Personal Information

Job Interests

Employment History

First Employer

Second Employer

Third Employer

Fourth Employer

Education Record

Additional Information

Professional License Information

Pre-Interview Questions

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

First Reference

Second Reference

Third Reference