Job Application

Date

First Name

Last Name

Phone Number

Are you older then 18?

Yes

Driver's License State & Number?

Job(s) Applying For:

Address

Physical Address

Mailing Address (If Different then Physical)

City

State

Zip Code

Country

Emergency Contact (Name and Phone Number)

Family/Friend Currently Working at MCHS

Start Date If Hired

Desired Salary

Available Shift

Shift Length:

Job Status:

Have you ever been Sanctioned for Medicare or Medicaid Fraud or Abuse?

Yes

Were you ever discharged/asked to resign by an employer?

Yes

Have you ever been convicted of a misdemeanor or a felony under any name? (A “yes” answer does not automatically disqualify you for employment)

Yes

If Yes, please explain.

Are you prevented from lawfully becoming employed in this country because of Visa or immigration status?

Yes

Have you worked for the Morton County Health System before?

Yes

Have you filed an application with the Morton County Health System before?

Yes

Are you capable of performing in a reasonable manner, with or without any reasonable accommodation, the activities involved in the job or occupation for which you have applied? A review of activities involved in such a job or occupation has been given.

Yes

What Skills and abilities do you have for the job you have applied for?

Education

High School

Address Line 1

City

State

Zip Code

Country

High School Diploma?

Yes

GED?

Yes

College or other School attended:

Diploma, Degree or Certification:

College or other School attended:

Diploma, Degree or Certification:

Current/Past Employer

Past Job 1

Past Company Address

Address Line 1

City

State

Zip Code

Country

Supervisor Name:

Supervisor's Title:

Supervisor Phone Nuumber:

Start Date:

End Date:

Job Status

Position Title:

Reason For Leaving:

Current Job Duties/Responsibilities:

Past Job 2

Past Company Address

Address Line 1

City

State

Zip Code

Country

Supervisor Name:

Supervisor's Title:

Supervisor Phone Nuumber:

Start Date:

End Date:

Job Status

Position Title:

Reason For Leaving:

Current Job Duties/Responsibilities:

Past Job 3

Past Company Address

Address Line 1

City

State

Zip Code

Country

Supervisor Name:

Supervisor's Title:

Supervisor Phone Nuumber:

Start Date:

End Date:

Job Status

Position Title:

Reason For Leaving:

Current Job Duties/Responsibilities:

I have read and agree to the Pre-Employment Certification.

Pre-Employment Certification

If employed, I agree to conform to the Morton County Health System rules, regulations and instructions as made known to me at the time of employment or any subsequent time. I also agree to have a tuberculosis skin test and a post offer physical examination as a condition of employment. All offers of employment made by Morton County Health System are expressly dependent upon the candidate’s successful completion of the tests. I consent and agree that Morton County Health System may conduct unannounced searches of lockers, desks and other areas I may use from time to time and seize any drugs, alcohol, weapons or other items not required in the performance of my duties. In accordance with Morton County Health System’s drug and alcohol testing policy, I understand that if I test positive for the substances listed on the Morton County Health System policy, my employment may be immediately terminated. Further, I understand that if my criminal background check is not clear, my employment may be immediately terminated. I understand that providing additional information other than that requested on this application may result in immediate disqualification from further consideration. Morton County Health System must operate 24 hours a day, seven days a week. Therefore, I understand that I may be required to work various and differing call times, rotation shifts and hours, including evening and night hours and shifts, Saturdays, Sundays, holidays and overtime in accordance with existing state laws. I further understand and agree that I will work where and when assigned by this facility and perform tasks assigned to me by this facility. I understand that I may be moved to different locations, assignments and departments from time to time as needed to meet staffing needs and requirements. My failure to do so may subject me to immediate dismissal by Morton County Health System. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer. I understand and agree that, if hired, my employment at Morton County Health System is at-will, for no definite period and may, regardless of the day of payment of my wages and salary, be terminated at any time with or without cause and without prior notice. Any representation to the contrary is void.

Agreement to release Authorization:

Yes