641-743-2123

Application for Employment


It is the policy of this facility to provide equal opportunity to any persons, regardless of race, religion, age, gender, disability, or any other classification in accordance with federal, state and local statues, regulations and ordinances.

Please fill out the application below as fully and completely as possible.

Personal Information



Yes
No


Full-Time


Part-Time


PRN


Temporary


Weekend Options


Days


Evening


Nights


Weekends


Newspaper


Referred by an employee


Other


No


Yes




No


Yes

Education

Professional Licenses and/or certificates

employment


Give a complete record of all employment and reasons for period of employment. Include volunteer work, etc. Start with present or most recent employer.

From:


 Full-Time
 Part-Time
 Other

May we contact this employer?

  Yes
  No

From:


 Full-Time
 Part-Time
 Other

May we contact this employer?

  Yes
  No

From:


 Full-Time
 Part-Time
 Other

May we contact this employer?

  Yes
  No

References


Give name(s) of person(s) we may contact to verify your qualifications for the position.





Have you ever been excluded from participation in any federal or state Medicare, Medicaid or any other third party payor program or have such pending action??

  Yes
  No

If yes, a letter showing reinstatement is required for further consideration for employment. I understand that I am required to immediately notify Adair County Health System if any action is proposed to exclude me from participation in any federal or state Medicare, Medicaid or third party payor program.

I certify that the information contained in this application is correct and I understand and agree that the falsification, misrepresentation or omissions of any information in this application are grounds for refusal to hire or if I have been hired, grounds for termination. I authorize investigation of all matters contained in this application. I understand and agree that if, in the judgment of Adair County Health System, the results of the investigation are not satisfactory, any offer of employment may be withdrawn or my employment with Adair County Health System may be terminated. I authorize the references listed in this application, including personal and employment references and all prior employers, toprovide you with all information pertinent to this application. I release all parties from liability for any damages that may result from the release of any information as a part of the employment verification process.

All successful applicants must pass a physical exam and drug screen and criminal background check prior to beginning employment with
Adair County Health System. I understand that an offer of employment is contingent upon my passing the health system’s medical examination before starting work.The examination may include a demonstration of my ability to perform the essential functions of the job. If the examination discloses conditions that prevent me from safely and successfully performing the essential function of the job, Adair County Health System will attempt to make accommodations that will enable me to work. If no reasonable accommodations can be found, or if such accommodations impose undue hardship on the health system, the offer of employment will be withdrawn.

I further acknowledge that I understand Adair County Health System has a policy of
employment at will and if I am hired by Adair County Health System my employment may be terminated either by myself or by the health system at any time.

I understand that employment is contingent upon successful completion of a job-required
licensure, certification, or registration exam, if applicable and not already completed.
  By checking this box, I am acknowledging that I have read and agree with the terms outlined above, and that submitting the form will act as my signature.