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We want to hear from you! If you have any questions or comments concerning South Central Kansas Medical Center, our services or this web site, please feel free to contact us.

 

           

123 Street Avenue, City Town, 99999

(123) 555-6789

email@address.com

 

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General Application

The SCKMC application process consists of three forms:

1. General Application   2. Release Authorization   3. Confidentiality Agreement

Please complete ALL THREE forms.
 

Name *
Name
Present Address *
Present Address
Previous Address
Previous Address
Home Phone *
Home Phone
Cell Phone
Cell Phone
Type of Position: *
Shift *
The ability to get to work on time each day and when called in on short notice during normal working hours?
How did you learn about this position?
If you answer "yes" to this question you will NOT be automatically disqualified from employment consideration, except as required by State or Federal law.
If you answer "yes" to this question you will NOT be automatically disqualified from employment consideration, except as required by State or Federal law.
Include school name, City, State, if you graduated/GED if not last level completed (9,10,11)
FOR EACH SCHOOL: Include school name(s), City, State, if you graduated if not last level completed (1,2,3,4), and degree or certificate received.
FOR EACH SCHOOL: Include school name(s), City, State, if you graduated if not last level completed (1,2,3,4), and degree or certificate received.
FOR EACH: Include school name(s), City, State, if you graduated if not last level completed (1,2,3,4), and degree or certificate received.
Include start and end dates (month and year). Company name, phone number, address, and immediate supervisor. Job title, job status (full-time, part-time, PRN), # of hours worked per week, salary. If your name has changed, include name while employed, summarize the nature of work performed and job responsibilities, and reason for leaving.
May we contact this company?
Include start and end dates (month and year). Company name, phone number, address, and immediate supervisor. Job title, job status (full-time, part-time, PRN), # of hours worked per week, salary. If your name has changed, include name while employed, summarize the nature of work performed and job responsibilities, and reason for leaving.
Include start and end dates (month and year). Company name, phone number, address, and immediate supervisor. Job title, job status (full-time, part-time, PRN), # of hours worked per week, salary. If your name has changed, include name while employed, summarize the nature of work performed and job responsibilities, and reason for leaving.
Include start and end dates (month and year). Company name, phone number, address, and immediate supervisor. Job title, job status (full-time, part-time, PRN), # of hours worked per week, salary. If your name has changed, include name while employed, summarize the nature of work performed and job responsibilities, and reason for leaving.
Provide name, company, position, address including City & State, work & home phone, and # of years known.
Provide name, company, position, address including City & State, work & home phone, and # of years known.
Provide name, company, position, address including City & State, work & home phone, and # of years known.
Professional License / Registration #1
Include type, number, state issued, and date.
Has license or registration EVER been suspended, revoked, or on probation? If YES, explain:
Professional License / Registration #2
Include type, number, state issued, and date.
Has license or registration EVER been suspended, revoked, or on probation? If YES, explain:
Professional Certifications #1
Include type, state issued, and date.
Professional Certifications #2
Include type, state issued, and date.
South Central Kansas Medical Center is an equal opportunity employer. South Central Kansas Medical Center does not discriminate in employment on account of race, color, religion, national origin, citizenship status, ancestry, age, sex (including sexual harassment), sexual orientation, marital status, physical or mental disability, military status or unfavorable discharge from military service. I hereby affirm that the information provided on this application is true and complete. I understand that any false or misleading reprentations or omissions made on the application or during the hiring process may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date. I understand that employment may be conditioned upon successfully passing a medical examination and that I may be required to satisfactorily complete a drug screening along with a background investigation as a condition of employment. I hereby authorize persons, schools, my current employer (if applicable) and previous employers and other organizations to provide this facility and its affiliates with any requested information regarding my application or suitability for employment, and I completely release all such persons or entities from any and all liability related to the providing or use of such information. I understand that my employment is at-will which means that I may terminate the employment relationship at any time and for any reason with or without notice, and that the facility has the same right. I understand that no one has the authority to enter into any agreement contrary to the preceding sentence, except for a written agreement signed by an administrative representative of this facility and notarized.