801 Locust Street     LaCrosse, Kansas 67548
Choose Rush County Memorial Hospital and Medical Clinic for your healthcare needs
APPLICATION FOR EMPLOYMENT
First Name:*
Middle Name:*
Last Name:*
RUSH COUNTY MEMORIAL HOSPITAL
8TH & LOCUST - BOX 520
LA CROSSE, KANSAS 67548
(785)222-2545

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.   (EQUAL OPPORTUNITY EMPLOYER)
Position(s) applied for:*
Date of application:*
Referral Source:
Name of Source (if applicable):
​Street Address:*
City:*
State:*
Zip Code:*
Phone Number:*
Home:
Cell Phone:*
Work:
If necessary, best time to call you at home.
May we contact you at work and what time?
Best time to reach you:
If you are under 18 and it is required, can you furnish a work permit?
If no, please explain.
Have you submitted an application here before?
If yes, give date(s)
Have you ever been employed here before?
If yes, give date(s)
Are you legally eligible for employment in this country?
Date available for work.
Type of employment desired
Employment History
Provide the following information for your past and current employers, assignments or volunteer activities, starting with the most recent event.
Employer:
Phone Number:
Address:
Job Title:
Immediate Supervisor and Title:
Reason for Leaving:
Date Employed:
to
May we Contact?
If no, Please explain:
Hourly Rate START:
FINAL:
Employer:
Phone Number:
Address:
Job Title:
Immediate Supervisor and Title:
Reason for Leaving:
Date Employed:
to
May we Contact?
If no, Please explain:
Hourly Rate START:
FINAL:
Summarize the type of work performed and job responsibilities:
EMPLOYER #1
EMPLOYER #2
Summarize the type of work performed and job responsibilities:
Employer:
Phone Number:
Address:
Job Title:
Immediate Supervisor and Title:
Reason for Leaving:
Date Employed:
to
May we Contact?
If no, Please explain:
Hourly Rate START:
FINAL:
Summarize the type of work performed and job responsibilities:
EMPLOYER #3
EDUCATIONAL BACKGROUND
(List last 3 schools attended, starting with the most recent.)
School:
Number of years completed:
Degree/Diploma/Certificate:
GPA:
Field of study:
Major:
Minor:
Date Completed:
School #1
School:
Number of years completed:
Degree/Diploma/Certificate:
GPA:
Field of study:
Major:
Minor:
Date Completed:
School #2
School:
Number of years completed:
Degree/Diploma/Certificate:
GPA:
Field of study:
Major:
Minor:
Date Completed:
School #3
List other qualifications not mentioned that you have that make you a good candidate for this position.
(Summarize any special training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.)
List special accomplishments, publications, awards, etc.(Exclude information which would reveal race, religion, national origin, sex, age, color, disability or other protected status.)
Comments.(Including Explanation of any Gaps in Employment)
​REFERENCES
(List name and phone number of three business/work references "not" related to you. Supervisors preferred. If not applicable, list three school or personal references who are "not" related to you.)
Reference #1
Name:*
Phone Number:*
Years Known:*
Reference #2
Name:*
Phone Number:*
Years Known:*
Reference #3
Name:*
Phone Number:*
Years Known:*
* Required fields
I understand that if I am employed, any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate discharge from the employer's service, whenever it is discovered.

I give the employer the right to contact and obtain information from all references, employers, educational institutions and to otherwise verify the accuracy of the information contained in this application. I hereby release from liability the employer and its representatives for seeking, gathering and using such information and all other person, corporations or organizations for furnishing such information.

The employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by local, state or federal law.

This application is current for only 60 days. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no representative of the employer, other than an authorized officer, has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by an authorized officer.

I understand it is the company's policy not to refuse to hire a qualified individual with a disability because of that person's need for a reasonable accommodation as required by the ADA.

I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization.




I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions.


Signature of Applicant:
FIRST, MIDDLE AND LAST NAME