First Name:*

Middle Initial:

Last Name:*

Home Phone:*

  Preferred

Work Phone:

  Preferred

Cell Phone:

  Preferred

Pager:

  Preferred

Email:*

Address:*

City:*

State:*

Zip Code:*

County:*

Country:

Alternate Address:

City:

State:

Zip Code:

County:

Country:

Job Position Applied For:*

Are you a U.S. citizen, or an alien legally authorized to work in the United States?*

Yes   No

Are you 18 years of age or older:

Yes   No

Please Specify your Shift Preference:*
Select all that apply.

ANY   Days   Evenings   Nights   Per Diem   Raotation   Variable   Weekends  

High School:

Last Year Completed:

1   2   3   4

Did you graduate?

Yes   No

College:

Course of Study:

Last Year Completed:

1   2   3   4   6   8

Did you graduate?

Yes   No

Degree earned:

Other College or Trade School:

Course of Study:

Last Year Completed:

1   2   3   4   6   8

Did you graduate?

Yes   No

Degree earned:

Other education:

Professional License/Certification:

What type of license/certification do you have/are you eligible for?

Has this License or Registration EVER been suspended, revoked or on probation?

Yes   No

Explain:

Are you a current employee of the Galena-Stauss Hospital & Healthcare Center?

Yes   No

If yes, how long have you been in your current position?

Have you ever been employed by Galena-Stauss Hospital & Healthcare Center?

Yes   No

If yes, when?

Current or most recent employment:

Job Title:

Employer:

Period of Employment
(please use MM/DD/YYYY format):

Salary:

(list Hr/Mo/Yr)

Supervisor:

Supervisor's Phone Number:

Duties:

Reason for Leaving:

Previous employment:

Job Title:

Employer:

Period of Employment:
(please use MM/DD/YYYY format)

Salary:

(list Hr/Mo/Yr)

Supervisor:

Supervisor's Phone Number:

Duties:

Reason for Leaving:

Previous employment:

Job Title:

Employer:

Period of Employment:
(please use MM/DD/YYYY format)

Salary:

(list Hr/Mo/Yr)

Supervisor:

Supervisor's Phone Number:

Duties:

Reason for Leaving:

Previous employment:

Job Title:

Employer:

Period of Employment:
(please use MM/DD/YYYY format)

Salary:

Supervisor:

Supervisor's Phone Number:

Duties:

Reason for Leaving:

May we contact the employers listed above?

Yes   No

If not, please indicate below which ones you do not wish us to contact.

For reference purposes, if you were under another name for any of the above employers please indicate that name.

Note: Conviction means you were found guilty by a judge, a jury, by pleading "no contest," or by pleading guilty in court. A conviction may have taken place even if you did not pay a fine or spend any time in jail or prison. A conviction will not automatically disqualify you from employment.

Have you ever been convicted of a felony or a misdemeanor (including, but not limited to such offenses as DUI, battery, theft, writing worthless checks, etc.)?*

Yes   No

If yes, what charges and dates?

Have you ever pled nolo contendere or pled guilty to a crime, which is a felony or a misdemeanor (including, but not limited to such offenses as DUI, battery, theft, writing worthless checks, etc.)?*

Yes   No

If yes, what charges and dates?

Have you ever had the adjudication of guilt withheld to a crime, which is a felony or a misdemeanor (including, but not limited to such offenses as DUI, battery, theft, writing worthless checks, etc.)?*

Yes   No

If yes, what charges and dates?

Provision of the following information is voluntary and a refusal to provide such information will have no effect on the company's employment decision. Applicants are considered for positions without regard to race, color, religion, sex, national origin, sexual preference, age, marital status, medical condition, disability, or other legally protected status.

Sex:

Race:

Agree*  

I have completed all appropriate fields on the above application, and have read the following paragraphs:

I will not violate the nepotism policy, which states that an employee related by blood or marriage shall not permanently work under the direct or indirect supervision of a relative unless they are removed by two administrative levels of supervision.

I understand that I might have to work rotating shifts and am able to do so. I certify that all of the information I have given in this document is accurate and complete and is subject to verification by the Galena-Stauss Hospital & Healthcare Center. In addition, my previous and present employers may be asked for information relative to my employment record with them. I understand that any omission or misrepresentation of material facts in this document may result in disqualification and/or disciplinary action. Further, in cases where job specifications state that I must meet certain educational requirements, I must be able to submit to the Human Resources Department: a high school diploma, general educational development (GED) certificate, a transcript of my college credits and/or copy of my degree, diploma or certification, as appropriate.

Please Note: This online application is not an offer for a contract of employment.