RCH Employment Application

APPLICANT INSTRUCTIONS

If you need help filling out this application form or for any phase of the employment process, please notify the person that gave you this form and every effort will be made to accommodate your needs in a reasonable amount of time.

  1. Please read "APPLICANT NOTE" below.
  2. Complete both sides of this page.
  3. If more space is needed to complete any question, use comments section at the bottom of this page.
  4. Print clearly: incomplete or illegible applications will not be processed. PLEASE NOTE "NOT APPLICABLE" IF NOT ANSWERING A QUESTION.
  5. Provide only requested information. Failure to do so may result in disqualification of your application.

APPLICANT NOTE

This application form is intended for use in evaluating your qualifications for employment. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment, terminating employment. All qualified applicants will receive consideration without discrimination based on sex, marital status, race, color, age, creed, national origin, sexual orientation, military reserve membership, ancestry, religion, height, weight, use of a guide or support animal because of blindness, deafness or physical handicap, or the presence of disabilities. A conviction will not necessarily bar an applicant from employment. Additional testing of job-related skills and for the presence of drugs in your body may be required prior to employment. After an offer of employment, and prior to reporting to work, you may be required to submit to a medical review. Depending on company policy and the needs of the job, you will be required to complete a medical history form and may be required to be examined by a medical professional designated by the company.

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Name
Current Address
Prior Address

Availability

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What category would you prefer?
For which schedules are you available? Reasonable efforts will be made to accommodate sincerely held religious beliefs and practices.

Job Related Skills

NOTE: Do not fill out any part of this section you believe to be non-job related.
If the job requires, do you have the appropriate valid drivers license?
Have you had any moving violations within the last seven years?
Have you been given a job description or had the essential functions of the job explained to you?
Do you understand these essential functions?
Can you perform the essential functions of this job with or without reasonable accommodation?

Security

Have you used any names or Social Security Numbers other than given above? If so, please list in comments, below.
Have you been convicted of a crime in the past seven years? If so, please describe in the boxes below. (Conviction will not necessarily be a bar to employment. In accordance with company policy and applicable state and federal laws, factors such as age at time of the offence, remoteness of the offense, time since last conviction, nature of the job sought and rehabilitation effort will be reviewed.)
Incident 1
Incident 1
Incident 1
Incident 2
Incident 2
Incident 2

Previous Employers

Most Recent Employer
Are you currently working for this employer?
If yes, may we contact?
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Most Recent Employer
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Most Recent Employer
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References

Include only individuals familiar with your work ability. Do not include relatives.
Reference 1
Reference 1
Reference 1
Reference 2
Reference 2
Reference 2

Education

NOTE: Do not fill out any part of this sections you believe to be non-job related. Please circle highest grade completed. 7 8 9 10 11 12 13 14 15 16 16+
High School
College
Other

Certification and Release

I certify that I have read and understand the applicant note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in the application, whether on this document or not, may result in rejections of my application or discharge at any time during my employment. I authorize Rooks County Health Center and/or its agents, including consumer reporting bureaus, to verify any of this information. I release all former employers, persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.
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