Employment Application Home> Careers> Employment Application> 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 InformationName* First Middle Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 InterestsPosition Desired* Date Available MM slash DD slash YYYY Alternate Position Desired: Position Full-time Part-time Contingent Temp Summer PRN 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 Job Fair Friend Walk-in Internet Other Advertisement 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.Employment HistoryAre you presently employed?* Yes No First EmployerName* Your Position Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employed From MM slash DD slash YYYY Employed To MM slash DD slash YYYY Starting Hourly Wage Final Hourly Wage Description of Work Performed Reason for leaving May we contact this employer?* Yes No Second Employer Add a Second Employer? Second EmployerName Your Position Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employed From MM slash DD slash YYYY Employed To MM slash DD slash YYYY Starting Hourly Wage Final Hourly Wage Description of Work Performed Reason for leaving May we contact this employer?* Yes No Third Employer Add a Third Employer? Third EmployerName Your Position Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employed From MM slash DD slash YYYY Employed To MM slash DD slash YYYY Starting Hourly Wage Final Hourly Wage Description of Work Performed Reason for leaving May we contact this employer?* Yes No Fourth Employer Add a Fourth Employer? Fourth EmployerName Your Position Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employed From MM slash DD slash YYYY Employed To MM slash DD slash YYYY Starting Hourly Wage Final Hourly Wage Description of Work Performed Reason for leaving May we contact this employer?* Yes No Education RecordName & Address of SchoolCourse of Study Years Attended Did you graduate?* Yes No Degree/Diploma Second School Add a Second School? Name & Address of SchoolCourse of Study Years Attended Did you graduate?* Yes No Degree/Diploma Third School Add a Third School? Name & Address of SchoolCourse of Study Years Attended Did you graduate?* Yes No Degree/Diploma Fourth School Add a Fourth School? Name & Address of SchoolCourse of Study Years Attended Did you graduate?* Yes No Degree/Diploma Academic honors or special recognition Have you ever served as a volunteer?* Yes No Please explain where and when you volunteered, what skills you used, and what jobs you performed. Additional InformationProfessional License Information If applicable, list all professional licensure information.Profession State IssuedPlease select a state...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificNumber Expiration Date MM slash DD slash YYYY Second License Add a Second License? Profession State IssuedPlease select a state...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificNumber Expiration Date MM slash DD slash YYYY Third License Add a Third License? Profession State IssuedPlease select a state...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificNumber Expiration Date MM slash DD slash YYYY Fourth License Add a Fourth License? Profession State IssuedPlease select a state...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificNumber Expiration Date MM slash DD slash YYYY If applicable, list all professional registration/certification information.Organization/Profession Number Expiration Date MM slash DD slash YYYY Second Organization/Profession Add a Second Organization/Profession? Organization/Profession Number Expiration Date MM slash DD slash YYYY Third Organization/Profession Add a Third Organization/Profession? Organization/Profession Number Expiration Date MM slash DD slash YYYY Fourth Organization/Profession Add a Fourth Organization/Profession? Organization/Profession 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: 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 positionFirst ReferenceName Occupation Organization Relationship Telephone Number Address Second ReferenceName Occupation Organization Relationship Telephone Number Address Third ReferenceName Occupation Organization Relationship Telephone Number 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 Attach ResumeAccepted file types: pdf, doc, docx, txt, rtf, Max. file size: 32 MB.Captcha
