Logan County Hospital

Oakley, Kansas

PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE
APPLICATION FOR EMPLOYMENT
APPLICANTS MAY BE TESTED FOR ILLEGAL DRUGS BEFORE AND DURING EMPLOYMENT
PLEASE COMPLETE PAGES 1-5.						DATE ________________________________
Name __________________________________________________________________________________________
Last First Middle
Present address __________________________________________________________________________________
Number Street City State Zip
How long ___________________			Social Security No. _______ – _____ – _________
Telephone ( )
If under 18, please list age ____________________
Position applied for (1)_______________________ and salary desired (2) ______________________ (Be specific)				Days/hours available to work No Pref _______ Thur _________ Mon __________ Fri __________ Tue __________ Sat _________ Wed _________ Sun _________
How many hours can you work weekly? _______________________ Can you work nights? _______________________
Employment desired qFULL-TIME ONLY qPART-TIME ONLY qFULL- OR PART-TIME
When available for work?______________
________________________________________________________________________________________________
TYPE OF SCHOOL	NAME OF SCHOOL	LOCATION (Complete mailing address, if possible)			NUMBER OF YEARS COMPLETED		MAJOR & DEGREE
High School
College
Bus. or Trade School
Professional School
HAVE YOU EVER BEEN CONVICTED OF A CRIME? q No q Yes
If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation. _______________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE		Logan County Hospital
APPLICATION FOR EMPLOYMENT
Please complete the following if driving is or may be an essential function of the job for which you are applying.
DO YOU HAVE A DRIVER’S LICENSE? q Yes q No
What is your means of transportation to work? ___________________________________________________________
Driver’s license number ___________________________ State of issue _______ q Operator q Commercial (CDL) qChauffeur
Expiration date ______________________
Have you had any accidents during the past three years?				How many? _________________
Have you had any moving violations during the past three years?				How Many? __________________
	All applicants please complete the following
q Yes q Yes Word q Yes Typing q No _____ WPM 10-key q No Processing q No _____ WPM
Personal q Yes PC q Computer q No Mac q			Other __________________________________________ Skills __________________________________________
Please list two references other than relatives or previous employers.
Name ______________________________________			Name _________________________________________
Position _____________________________________			Position _______________________________________
Company ___________________________________			Company ______________________________________
Address ____________________________________			Address _______________________________________
_____________________________________			_______________________________________
Telephone ( )			Telephone ( )
An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.

PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE		Logan County Hospital
APPLICATION FOR EMPLOYMENT
			MILITARY
HAVE YOU EVER BEEN IN THE ARMED FORCES? q Yes q No
ARE YOU NOW A MEMBER OF THE NATIONAL GUARD? q Yes q No
Specialty _________________________________ Date Entered ________________ Discharge Date ______________
Work Experience	Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name. Attach additional sheets if necessary.
Name of employer Address				Name of last supervisor	Employment dates	Pay or salary
City, State, Zip Code Phone number					From To	Start Final
				Your last job title
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
Name of employer Address				Name of last supervisor	Employment dates	Pay or salary
City, State, Zip Code Phone number					From To	Start Final
				Your Last Job Title
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE	Logan County Hospital
APPLICATION FOR EMPLOYMENT
Continued work experience
Name of employer Address		Name of last supervisor	Employment dates	Pay or salary
City, State, Zip Code Phone number			From To	Start Final
		Your last job title
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
Name of employer Address		Name of last supervisor	Employment dates	Pay or salary
City, State, Zip Code Phone number			From To	Start Final
		Your last job title
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
May we contact your present employer? q Yes q No
Did you complete this application yourself