Untitled Document

Johnson County Healthcare Center

497 West Lott – Buffalo, WY 82834

APPLICATION FOR EMPLOYMENT

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

Name Social Security # - -

Last First Middle

Address

Street City State Zip Code

Telephone # ( ) Mobile/Beeper/Other Phone # ( ) E-mail Address

Position(s) applied for: Date of application / /

If necessary, best time to call you at home is am/pm May we contact you at work? rYes rNo If yes, work number and best time to call: ( ) am/pm If you are under 18 and it is required, can you furnish a work permit? rYes rNo If no, please explain Have you submitted an application here before? rYes rNo If yes, give date(s) and position(s) Have you ever been employed here before? rYes rNo If yes, give dates From____/ _/____ To____/ _ /___ Are you legally eligible for employment in this country? rYes rNo Date available for work ____/ _ /___ What is your desired salary range or hourly rate of pay? $ Per Type of employment desired: r Full-Time r Part-Time r Educational Co-Op r Seasonal r Temporary Will you relocate if job requires it? rYes rNo			Will you travel if job requires it? rYes rNo If they have been explained to you, are you able to meet the attendance requirements of the position? rYes rNo Will you work overtime it required? rYes rNo If no, please explain Driver’s license number required if driving may be required in the job for which you are applying: State Have you ever been bonded? rYes rNo Answering “yes” to the following question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account. Have you ever pled “guilty” or “no contest” to, or been convicted of a crime? rYes rNo If yes, please provide date(s) and details
Employment History
Starting with your most recent employer, provide the following information.
Employer Telephone # ( )				Month Year Month Year Dates employed: / to /
Street address City State				Compensation (Starting)
				r Hourly r Salary		$ per
Starting job title/final job title				Compensation/Bonus/ Other Compensation $
Immediate supervisor and title (for most recent position held)	r Hourly r Salary			Compensation (Final)
				r Hourly r Salary		$ per
Why did you leave?				Compensation/Bonus/ Other Compensation $
Summarize the type of work performed and job responsibilities.
What did you like most about your position?
What did you like least about your position?
Employment History (continued)
Starting with your most recent employer, provide the following information.
Employer Telephone # ( )					Month Year Month Year Dates employed: / to /
Street address City State					Compensation (Starting)
					r Hourly r Salary		$ per
Starting job title/final job title					Compensation/Bonus/ Other Compensation $
Immediate supervisor and title (for most recent position held)		r Hourly r Salary			Compensation (Final)
					r Hourly r Salary		$ per
Why did you leave?					Compensation/Bonus/ Other Compensation $
Summarize the type of work performed and job responsibilities.
What did you like most about your position?
What did you like least about your position?
Employer Telephone # ( )					Month Year Month Year Dates employed: / to /
Street address City State					Compensation (Starting)
					r Hourly r Salary		$ per
Starting job title/final job title					Compensation/Bonus/ Other Compensation $
Immediate supervisor and title (for most recent position held)		r Hourly r Salary			Compensation (Final)
					r Hourly r Salary		$ per
Why did you leave?					Compensation/Bonus/ Other Compensation $
Summarize the type of work performed and job responsibilities.
What did you like most about your position?
What did you like least about your position?
Employer Telephone # ( )					Month Year Month Year Dates employed: / to /
Street address City State					Compensation (Starting)
					r Hourly r Salary		$ per
Starting job title/final job title					Compensation/Bonus/ Other Compensation $
Immediate supervisor and title (for most recent position held)		r Hourly r Salary			Compensation (Final)
					r Hourly r Salary		$ per
Why did you leave?					Compensation/Bonus/ Other Compensation $
Summarize the type of work performed and job responsibilities.
What did you like most about your position?
What did you like least about your position?
Explain any gaps in your employment, other than those due to personal illness, injury or disability. If not addressed above or on the previous page, have you ever been fired or asked to resign from a job? rYes rNo If yes, please explain
Skills and Qualifications
Summarize any special training, skills, licenses and/or certificates that may assist you in performing the position for which you are applying. Computer Skills (Check appropriate boxes. Include software titles and years of experience.) r Word Processing Years r Internet Years r Spreadsheet Years r Other Years r Presentation Years r Other Years r E-mail Years r Other Years

Educational Backgrounds
Starting with the most recent school attended, provide the following information.
School (Include City & State)		Years Completed			Completed		GPA Class Rank		Major/Minor
					r Diploma r GED r Degree r Certification r Other
					r Diploma r GED r Degree r Certification r Other
					r Diploma r GED r Degree r Certification r Other
					r Diploma r GED r Degree r Certification r Other
					r Diploma r GED r Degree r Certification r Other

References
List name and telephone number of three business/work references who are not related to you and are not previous supervisors. It not applicable, list three school or personal references who are not related to you.
Name	Title			Relationship to You		Telephone		Number of Years Known
						( )
						( )
						( )

Related Information
To what job-related organizations (professional, trade, etc.) do you belong? Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve national guard or any other similarly protected status.
Organization			Offices Held




List special accomplishments, publications, award, etc. Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve national guard or any other similarly protected status.