Application

Careers

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About Yourself
First Name: *		M.I.: *	Last Name: *
Street Address: *
City / State / Zip: *
Email Address:
Daytime Phone #: *		Evening Phone #: *
Position Applied For: *
Position Posting Number:
Desired Wage / Salary:		Start Date (mm/dd/yy):		/ /
Type of Employment Desired: *	Full-Time Part-Time Temporary Other:
Preferred Shift:	Days Evenings Nights Weekends
Are you able to meet the attendance requirements of the position? *			Yes No
If you are under 18, can you furnish a work permit? *			Yes No
Are you legally eligible for employment in this country? * (Proof of U.S. Citizenship or immigration status will be required upon employment.)			Yes No
Have you been convicted of a felony in the last seven (7) years? *			Yes No
If so, please explain:
How were you referred to this facility?
Do you have relatives or friends employed here? *			Yes No
If so, which department?
Have you ever been employed by this facility? *			Yes No
If so, which department?

Skills & Qualifications
Summarize any training, skills, licenses, and certificates that may qualify you as able to perform job-related functions in the desired position:

Educational Background
High School Name:	Location:
Years Completed:	Did You Graduate?	Yes No
College Name:	Location:
Course of Study:
Years Completed:	Did You Graduate?	Yes No
Other School Name:	Location:
Course of Study:
Years Completed:	Did You Graduate?	Yes No

Employment History
List your last three (3) employers, assignments or volunteer activities, starting with the most recent.
Employer 1 Name:		Phone #:
Address:
Start Date:		End Date:
Starting Salary:		Ending Salary:
Position Held:
Summarize the nature of the work performed and job responsibilities:
May we contact for reference?	Yes No
Employer 2 Name:		Phone #:
Address:
Start Date:		End Date:
Starting Salary:		Ending Salary:
Position Held:
Summarize the nature of the work performed and job responsibilities:
May we contact for reference?	Yes No
Employer 3 Name:		Phone #:
Address:
Start Date:		End Date:
Starting Salary:		Ending Salary:
Position Held:
Summarize the nature of the work performed and job responsibilities:
May we contact for reference?	Yes No

References
Name: *
Phone #: *		Years Known: *
Name: *
Phone #: *		Years Known: *
Name: *
Phone #: *		Years Known: *

Voluntary Affirmative Action Information
In an effort to implement our voluntary government affirmative action program record keeping and reporting requirements, we ask that you complete this data survey. Your cooperation is appreciated. Providing this information is STRICTLY VOLUNTARY. Failure to provide it will have no role in our hiring decision. Information provided will be kept confidential in accordance with applicable regulations.
Gender:	Male Female
Race/ethnic Group:	White/Caucasian Black or African American Hispanic/Latino Asian American Indian/Alaskan Native Native Hawaiian or Pacific Islander Two or more races

I consent to any medical examination required by the facility at any time to determine my ability to perform the duties of my job or other jobs within the facility and I understand that any offer of employment may be contingent upon satisfactorily passing a physical examination. I also understand that I will be required to satisfactorily complete an alcohol/drug screening as a condition of employment.

It is understood and agreed upon that any misrepresentation by me on this application will be sufficient cause for cancellation of this application and/or separation from the employer's service if I have been employed.

I give the employer the right to investigate all references and to secure additional information about me, if job related. I hereby release from liability the employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing information.

The employer is an Equal Opportunity Employer. The employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state or federal law. I understand it is the company's policy not to refuse to hire a qualified individual with a disability because of this person's need for an accommodation that would be required by the ADA.

I understand that just as I am free to resign at any time, the employer reserves the right to terminate my employment at any time, with or without prior notice. I understand that no representative of the employer has the authority to make assurances to the contrary.

How to Apply by Mail or Email

Click here to download our Application for Employment (PDF).

Stop by the hospital in person to obtain an application. Once completed, the application can be returned to the receptionist.

Mail your resume or application to:
      Tomah Memorial Hospital
      Attn: Human Resources
      321 Butts Avenue
      Tomah, WI 54660

Email your resume to:
careers@tomahhospital.org

Those applicants requiring accommodations to the application process should contact a representative of Human Resources.

If you have any general questions, please e-mail careers@tomahhospital.org

Job Line: 608-374-6664
EOE/AA

Tomah Memorial Hospital

Taking care of you

Application

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How to Apply by Mail or Email