Perry County Memorial Hospital

	Job List

	Benefits

	Job Application

Date:

434 North West Street
Perryville, MO 63775
573-547-2536
EOE

APPLICATION FOR EMPLOYMENT

Have you ever been employed by Perry County Memorial Hospital?

Yes No

Have you ever applied at Perry County Memorial Hospital before today?

If yes, indicate month year

Yes No

TYPE OF WORK:

Position sought:

Full Time Part Time P.R.N.

Are you able to work weekends?	Yes No
Are you willing to work any shift?	Yes No
Are you willing to rotate shifts?	Yes No
Holidays?	Yes No
Date Available for Employment:

PERSONAL DATA:

Name:

Present Address:

Present City:

State:

Zip:

Phone Number:

Previous Address:

Previous City:

State:

Zip:

Date of Birth:

(Optional)

Social Security No.

In Case of Emergency, notify:

PHYSICAL DATA:

Can you safely perform the essential functions of the position for which you are applying?
Yes No

Are you willing to submit to a pre-employment drug screening and / or a physical examination at our expense upon a conditional offer of employment? Yes No

EDUCATION:

Name & Location of School \| Dates Attended \| Degree / Diploma \| Major Field of Study \| Years of Schooling Completed
High School
Post High School
Post High School #2
Post High School #3

PROFESSIONAL REGISTRATION OR LICENSE NO.

State

Year Attained

Expiration Date

PRIOR WORK HISTORY (Please note if name employed under is different from present name)

Present or Most Recent Employer:

Dates Employed:

Reason For Leaving:

Job Title:

Rate of Pay:

Supervisor’s Name and Title:
Describe in detail the work you did:

Present or Most Recent Employer:

Dates Employed:

Reason For Leaving:

Job Title:

Rate of Pay:

Supervisor’s Name and Title:
Describe in detail the work you did:

Present or Most Recent Employer:

Dates Employed:

Reason For Leaving:

Job Title:

Rate of Pay:

Supervisor’s Name and Title:
Describe in detail the work you did:

May we contact the employers listed above? Yes No

If not, indicate below which one(s) you do not wish us to contact.

PERSONAL REFERENCES (Excluding former employers or relatives)

1] Name and Occupation:

2] Name and Occupation:

3] Name and Occupation:

OFFICE SKILLS

Please list any office skills or computer program knowledge you may have:

MISCELLANEOUS

Have you ever been convicted of a felony?
Yes No

If yes, list all convictions (except traffic offenses) showing offense and date. (The listing of any criminal convictions will not necessarily disqualify you from consideration for employment.)

Do you have relatives working for the hospital? Yes No

If yes, please give their name (s) and department:

REMARKS

Make any comments you feel are pertinent to your application. Include any special training or experience which further qualifies you for employment.

READ CAREFULLY

“I hereby certify that my answers to the above are true and further that I understand that any information withheld or falsely provided by me in connection with the foregoing Application will subject me to immediate termination of employment. I also recognize that my employment is based on receipt of satisfactory information from former employers or references. I hereby authorize Perry County Memorial Hospital without liability to contact prior employers (present employers if authorized) or references given by me and authorize said employers or references to make full response to any inquiries by Perry County Memorial Hospital in connection with this Application for Employment. I also authorize Perry County Memorial Hospital to give any information concerning me or my employment in response to inquiries from subsequent potential employers or other inquiries concerning me without specific request and for my benefit. I hereby agree to hold harmless Perry County Memorial Hospital and all former employers or references listed on this application from any liability of claims or whatsoever nature. I also understand a conditional offer of employment may be based on results of a later medical examination. I agree to conform to the rules and regulations of Perry County Memorial Hospital, and understand that my employment and compensation can be terminated with or without cause, and with or without notice at any time at the option of either Perry County Memorial Hospital or myself. I further understand that no representative of Perry County Memorial Hospital other than the Administrator or his designee has any authority to enter into any agreement for employment for any specified period, or to make any agreement contrary to the foregoing. I further understand that the language of the Employee Manual is not to be construed as creating any form of employment agreement and that it does not serve as an independent basis of contract for employment. I further agree to abide by all rules and regulations in effect at the time of my employment or subsequently initiated. I also agree to work any shift in any department in cases of emergency. I also agree that upon my termination of employment (should I be hired) I will return all hospital property. I hereby authorize a reduction from my final payroll check for all hospital property not returned. I further certify that I have read the foregoing paragraph and herewith knowingly make this authorization by setting forth my signature below.”


Date	Signature of Applicant

INFORMATION TO APPLICANT

Perry County Memorial Hospital is an Equal Opportunity Employer and will not discriminate on the basis of race, sex, political affiliation, marital status, creed, color, national origin, religion, age, physical or mental impairment, medical condition, veteran status or any other legally protected status. Certain information requested on this form is for statistical or insurance purposes or for use in furnishing Affirmative Action Data to appropriate government agencies.

Your application is valid for a period of sixty (60) days. If you wish to be reconsidered for employment after sixty (60) days, then you must contact the Hospital Personnel Department.

*The age discrimination in Employment Act of 1967, as amended, prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age.

PERRY COUNTY MEMORIAL HOSPITAL – EQUAL OPPORTUNITY EMPLOYER

AGE
1. Under 40 years of age
2. Over 40 years of age

RACE
1. WHITE
2. BLACK
3. HISPANIC
4. AMERICAN INDIAN
5. ASIAN

SEX
1. Male
2. Female

DISABLED?
1. Yes
2. No

VETERAN STATUS
1. DISABLED VETERAN
2. VIETNAM ERA
3. OTHER VETERAN

WHAT LEAD YOU TO APPLY HERE?
1. STATE EMPLOYMENT AGENCY
2. PCMH BULLETIN BOARD
3. PCMH WEBSITE
4. PERRY COUNTY REPUBLIC MONITOR
5. STE. GENEVIEVE HERALD TRIBUNE
6. RANDOLPH COUNTY HERALD TRIBUNE
7. SOUTHEAST MISSOURIAN
8. DAILY JOURNAL
9. EMPLOYEE OF PCMH
10. A FRIEND

(OR)

434 N. West Street, Perryville, MO 63775
(573) 547-2536