EMPLOYMENT APPLICATION
* Denotes a required field
*Position:
*Name:
*Home Phone:
Business Phone:
*E.Mail Address:
*Street Address:
*City:
*State/ZIP:
*Are You a U.S. Citizen: Yes
No
If not, do you have a legal right to work in the U.S.: Yes
No
Shift Desired:
Full Time
Day Shift
As Needed
Part Time
Evening Shift		 Temporary
Night Shift
Summer
Any
*Minimum Salary Desired:
*Date Available:
Referred By:
Employee
Internet
Newspaper
Physician
School
 Recruiting Fair
Walk In
Radio / TV
Other
If Other, Specify:
*Have You Ever Been Employed By Prairie Lakes Healthcare System: Yes
No
If Yes Where:
Are You 18 Years or Older: Yes
No
If No What Is Your Age:
Have You Attended School or Been Employed Under Another Name: Yes
No
If Yes, What Name:
EDUCATION AND TRAINING
List Formal Schooling:
Degree(s) Obtained:
List Any Military Experience Which May Be Related To The Job For Which You Are Applying:
Graduated from High School? Yes No
EMPLOYMENT HISTORY
Start with your present or last job
Company Name:
Position:
Describe Duties:
Dates of Employment: from:

to:
Supervisor:
Phone:
Salary:
Reason For Leaving:
Company Name:
Position:
Describe Duties:
Dates of Employment: from:

to:
Supervisor:
Phone:
Salary:
Reason For Leaving:
Company Name:
Position:
Describe Duties:
Dates of Employment: from:

to:
Supervisor:
Phone:
Salary:
Reason For Leaving:
Company Name:
Position:
Describe Duties:
Dates of Employment: from:

to:
Supervisor:
Phone:
Salary:
Reason For Leaving:
Have You Ever Been Discharged or Forced to Resign From Any Position? Yes
No
If Yes, Explain:
*May Your Present Employer Be Contacted For Job References? Yes
No
*May Your Past Employer(s) Be Contacted For Job References? Yes
No
PROFESSIONAL REFERENCES
Name:
Present Title:
Phone:
Email:
Company Name & Address:
Name:
Present Title:
Phone:
Email:
Company Name & Address:
Name:
Present Title:
Phone:
Email:
Company Name & Address:
Name:
Present Title:
Phone:
Email:
Company Name & Address:
SPECIAL SKILLS AND QUALIFICATIONS
CRIMINAL RECORD
Have you ever pled "guilty" or "no contest" to, or been convicted of a crime? Yes
No

Answering yes, does not constitute an automatic bar to employment. Factors such as date of the offense, age at time of offense, seriousness and nature of violation, and rehabilitation, as well as position applied for will be taken into account.
If yes, please provide date(s) and details (you do not need to provide information regarding sealed, expunged, or statutorily eradicated convictions).
RESUME UPLOAD
Click browse to upload your resume with this application. Please use .doc or .pdf formats. Resume files must be smaller than 4MB.
CERTIFICATION AND AUTHORIZATION STATEMENT
I hereby certify that the statements contained in this application are true and correct to the best of my knowledge and belief.

I hereby authorize Prairie Lakes Healthcare System (PLHS) to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information.

I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, regardless of time of discovery.

I understand that any employment here is contingent on the results of a physical capacity assessment if required. I understand that if I am hired by PLHS my employment will be for an indefinite period of time and will be "at will" which means that either I or PLHS may terminate the employment relationship at any time and for any or no reason. I further understand that if hired my "at will" employment status may only be changed in a written contract signed by the Administrator or the Administrator's authorized representative, and that no representative of PLHS has the authority to make any oral promise to me concerning my employment. Finally, I also understand that while PLHS supports current policies and benefits, it retains the right to change them at any time, with or without notice. PLHS is committed to providing a safe, healthy, and productive work environment and supports a smoke free, alcohol and drug free work environment.

* I fully understand and agree to the above statement