Wayne County Hospital

Employment application

Pillars of Excellence

People: Employees are informed and have opportunities for improving their skills to promote success.

Quality: Provide easily accessible quality care.

Service: Initiate a culture where high quality service is evident to all physicians, patients, and employees.

Growth: Investigate and capitalize on opportunities to grow Wayne County Hospitals existing services and to develop new services.

Community: WCH will actively pursue opportunities to have a positive impact on community issues.

Finance: Meet or exceed operating budget indicators while securing long-term financial security.

I have read the above Pillars of Excellence and agree to uphold these standards if hired as an employee of Wayne County Hospital.
Applicant's Signature - Full Name:

PERSONAL INFORMATION

Name Phone ( ) -

First

Last

Area

Number

Present Address

Street

City

State

Zip

Email Address

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

JOB INTERESTS

Position Desired Date available

Alternate choice Full-time Part-time Contingent Temp Summer

If part-time, how many hours per week?

Please select the days you are willing to work S M T W T F S

What shifts can you work? Days Evenings Nights Holidays

What is your expected starting salary?

Have you ever been employed by this organization before? Yes No If yes, when?

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

How did you hear about the position?
Employment Agency Job Posting Job Fair Friend Walk-in Internet Other
Advertisement (please list publication)

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.

EDUCATION RECORD

School	Name and Address of School	Course of Study	(Optional) Years Attended From / To	Select Year Completed	Did You Graduate?	Degree/ Diploma
Post High School (i.e. College School of Nursing, Vocational, Technical School, Graduate level)			From: To:	1 2 3 4
			From: To:	1 2 3 4
			From: To:	1 2 3 4
			From: To:	1 2 3 4
High School			From: To:	9 10 11 12

Academic honors or special recognition

Have you ever served as a volunteer? Yes No
If yes, please explain where and when you volunteered, what sklls you used and what jobs you performed

Are you presently employed? Yes No

1.
Present or most recent Employer

Employment Dates

From
Mo.
Yr
To
Mo.
Yr

Name of Employer	Address:	Telephone Number ( )-
	Street
	City State

Your Position

Last Supervisor

Starting Salary

Final Salary

Description of work performed

Reason for leaving

May we contact this employer? Yes No

2.
Next Previous Employer

Employment Dates

From
Mo.
Yr
To
Mo.
Yr

Name of Employer	Address:	Telephone Number ( )-
	Street
	City State

Your Position

Last Supervisor

Starting Salary

Final Salary

Description of work performed

Reason for leaving

May we contact this employer? Yes No

3.
Next Previous Employer

Employment Dates

From
Mo.
Yr
To
Mo.
Yr

Name of Employer	Address:	Telephone Number ( )-
	Street
	City State

Your Position

Last Supervisor

Starting Salary

Final Salary

Description of work performed

Reason for leaving

May we contact this employer? Yes No

4.
Next Previous Employer

Employment Dates

From
Mo.
Yr
To
Mo.
Yr

Name of Employer	Address:	Telephone Number ( )-
	Street
	City State

Your Position

Last Supervisor

Starting Salary

Final Salary

Description of work performed

Reason for leaving

May we contact this employer? Yes No

ADDITIONAL INFORMATION

If applicable, list all professional licensure information

Profession State Issued Number Expiration Date

If applicable, list all professional registration/certification information:

Organization / Profession Number Expiration Date

If applicable, please 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 list any technical skills or knowledge you possess which are related to the position(s) for which your applying
(i.e. equipment, software, medical terminology):

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

REFERENCES

Give Name(s) of Professional References we may contact to verify your qualifications for the position
Name	Occupation	Organization
Relationship	Telephone Number	Address
Name	Occupation	Organization
Relationship	Telephone Number	Address
Name	Occupation	Organization
Relationship	Telephone Number	Address

PLEASE READ

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.