Employment Application

WE ARE AN EQUAL OPPORTUNITY EMPLOYER
Huron Regional Medical Center does not discriminate because of race, color, creed, age, sex, marital status, religion, disability, national origin, or veteran’s status. If you have any questions or need further assistance, please contact HRMC Human Resources at (605) 353-6539.

Please fill out application completely. An incomplete application may not be accepted. Your application will be kept on file for a period of one year.

In addition to completing this application, you will have an opportunity to upload your resume prior to submission.

Applicant Data:

Last Name: First Name: MI:
Street: City: State: Zip:
E-mail Address: Primary Phone: Secondary Phone:

Are you at least 16 years old? Yes No

Are you a citizen of the U.S. or otherwise lawfully authorized to work in the U.S.? Yes No

Have you ever been convicted of a felony? Convictions do not automatically disqualify an applicant from employment. The type and seriousness of the crime, the frequency of violations, the applicant’s age at the time of the conviction, and the date of conviction or time elapsed since the conviction or completion of any jail sentence will be taken into consideration in addition to other job-related criteria.
Yes No

Position/Job Information:

Position(s) Desired:

Status: check all that apply Full Time Part Time On Call

Date Available: Expected Rate of Pay:

Shift Choices:check all that apply Day Evening Night Weekend

Are you willing to rotate shifts? Yes No

How did you hear about this position? check all that apply School Bulletin Board Agency Walkin

Newspaper: Web Site: Referral, if so who: Other:

Name and relationship of any relative in our employ: (If none, write “None”)

Have you been previously employed by Huron Regional Medical Center: Yes No

If so, position: Dates:

Application Release: May your application be released to local clinics and other healthcare facilities provided they have any openings in your area of interest?
Yes No

Education Skills/Data:

Do you possess a high school diploma or GED?

Yes No

If not, last grade completed: 9 10 11 12

	Post High School Education School Name and Address	major(s) / minor(s) courses	Did you Graduate?	Degree or Number of Credits Earned
1.
2.
3.

List all relevant professional licenses, registrations, or certifications you possess:

Profession or trade name:

Professional License/Permit/Certification Number: State: Expiration Date:

Legal Compliance:

Have you ever been excluded from participation in the Medicare program?
Yes No

If yes, what was the date?

If yes, please explain:

Professional References:

(Please Do Not Include Relatives)

	Name and Complete Address	Business Affiliation	Telephone Number	Years Known
1.
2.
3.

Employment History:

Present or Last Employer Start (MM/YY) End Date Total Time Employed
Address City State Zip
Phone Job Title Supervisor's Name and Title

Detailed Description of Duties:

Salary: Reason for Leaving:

Full Time Part Time Hrs/Week: Temporary On Call

May We Contact?
Yes No

Second Previous Employer Start (MM/YY) End Date Total Time Employed
Address City State Zip
Phone Job Title Supervisor's Name and Title

Detailed Description of Duties:

Salary: Reason for Leaving:

Full Time Part Time Hrs/Week: Temporary On Call

May We Contact?
Yes No

Third Previous Employer Start (MM/YY) End Date Total Time Employed
Address City State Zip
Phone Job Title Supervisor's Name and Title

Detailed Description of Duties:

Salary: Reason for Leaving:

Full Time Part Time Hrs/Week: Temporary On Call

May We Contact?
Yes No

Fourth Previous Employer Start (MM/YY) End Date Total Time Employed
Address City State Zip
Phone Job Title Supervisor's Name and Title

Detailed Description of Duties:

Salary: Reason for Leaving:

Full Time Part Time Hrs/Week: Temporary On Call

May We Contact?
Yes No

Applicant Certification/Release of Information

Prior to submitting your application, please read the following carefully. Check each box and type your name and the date to indicate you agree to the terms. Your application will not be processed unless you agree to all of the terms listed below.

I hereby certify that all of the information provided by me in this application (or any accompanying documents) is correct, accurate and complete to the best of my knowledge. I understand that falsification and/or misrepresentation will be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery.

I hereby authorize HRMC to investigate my statements and conduct a background investigation if deemed necessary. All employers, educational institutions, law enforcement agencies, state and federal courts, and references listed are hereby authorized to give HRMC any and all information regarding my employment, background, or character. HRMC and all employers, educational institutions, law enforcement agencies, state and federal courts, and references are hereby released from any and all liability which may result from furnishing or using such information.

In consideration for employment with HRMC, if employed, I agree to conform to the rules, regulations, policies and procedures of HRMC at all times and understand that such obedience is a condition of employment. I understand that if offered a position with HRMC, I will be required to submit to a pre-employment health assessment and background check as a condition of employment. I understand that unsatisfactory results from, refusal to cooperate with, or any attempt to affect the results of the pre-employment assessment and/or background check will result in a withdrawal of any employment offer or termination of employment if already employed.

The use of this application does not indicate there are positions open and does not in any way obligate HRMC. Additionally, this application should not be considered as an employment agreement. Any decisions regarding length of employment, interpretation, or application of policies or procedures by the Hospital will be final and binding on all parties concerned. I further agree that my employment and compensation can be terminated at will, with or without cause and with or without notice, at anytime either at my option or at the option of HRMC.

Name: Date: