Tomah Memorial Hospital

Application for Employment

Equal access to programs, services and employment is available to all persons. Those applicants requiring accommodation to the application and/or interview process should contact a representative of the Human Resources Department.

Equal access to programs, services and employment is available to all persons. Those applicants requiring accommodation to the application and/or interview process should contact a representative of the Human Resources Department.

About Yourself
*First Name : *M.I.: *Last Name :
*Street Address:
*City: *State: *Zip:
*Daytime Phone #: *Evening Phone #:
*Position Applied For:
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? Yes No
(Proof of U.S. Citizenship or immigration status will be required upon employment.)
*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:
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:
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:
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
Hispanic
Asian/Pacific Islander
American Indian/Alaskan Native


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 may 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.