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Contact Us

Greene County Medical Center
1000 West Lincolnway
Jefferson, IA 50129
Phone: (515) 386-2114
Fax: (515) 386-3695
Contact Us

* Indicates required information
Date Available *    (mm/dd/yyyy)
First Name: * 
Middle Name: * 
Last Name: * 
Street Address 1: * 
Street Address 2: 
City: * 
State: * 
Zip: * 
Home Phone Number: * 
Alternate Phone Number: 
Email Address: * 
Position(s) Applying For:  * 
Will you accept employment of: * 
Are you 18 years of age or older? * 
If no, are you at least 16? * 
Have you ever been employed by Greene County Medical Center? * 
If yes, list your dates of employment 
Have you ever worked under another name? * 
If yes, give name(s): 
Are you able to perform the duties of the position for which you have applied with or without accommodation? * 
Do you have relatives employed at Greene County Medical Center? * 
If yes, please list their name(s) 
How did you hear of this opening? 

If Other, please specify:
Shifts you are willing to work: * 
 
EDUCATION
 
High School 
Name of School: 
Location (City/State): 
Course of Study: 
Graduated? 
Type of degree or certificate received: 
College/University 
Name of School: 
Location (City/State): 
Course of Study: 
Graduated? 
Type of degree or certificate received: 
Vocational or Business 
Name of School: 
Location (City/State): 
Course of Study: 
Graduated? 
Type of degree or certificate received: 
Other 
Name of School: 
Location (City/State): 
Course of Study: 
Graduated? 
Type of degree or certificate received: 
 
PROFESSIONAL LICENSES AND/OR CERTIFICATIONS
 
Type: 
License/Cert. Number: 
State Issued: 
Expiration Date: 
Type: 
License/Cert. Number: 
State Issued: 
Expiration Date: 
Is your professional license or has it ever been under investigation, suspended or revoked in this state or any other? * 
If yes, please explain. (Failure to disclose will result in disqualification from employment) 
 
EMPLOYMENT RECORD (list last or present position first)
 
Are you currently employed? * 
May we contact your present employer for reference? * 
If no, please explain or if not at this time please give a date when contact may occur: 
Company name: 
Address: 
City: 
State: 
Zip: 
Telephone: 
Name of Supervisor/Title 
Date employed from: 
To: 
Hourly Pay/Salary: 
Full Time/Part Time/PRN 


Postition held and describe duties: 
Reason for Leaving? 
Company Name: 
Address: 
City: 
State: 
Zip: 
Telephone: 
Name of Supervisor/Title: 
Date employed from: 
To: 
Hourly Pay/Salary: 
Full Time/Part Time/PRN? 


Position held and describe duties: 
Reason for Leaving? 
Company Name: 
Address: 
City: 
State: 
Zip: 
Telephone: 
Name of Supervisor/Title: 
Date employed from: 
To: 
Hourly Pay/Salary: 
Full Time/Part Time/PRN? 


Position held and describe duties: 
Reason for Leaving? 
Company Name: 
Address: 
City: 
State: 
Zip: 
Telephone: 
Name of Supervisor/Title: 
Date employed from: 
To: 
Hourly Pay/Salary: 
Full Time/Part Time/PRN? 


Position held and describe duties: 
Reason for Leaving? 
Company Name: 
Address: 
City: 
State: 
Zip: 
Telephone: 
Name of Supervisor/Title 
Date employed from: 
To: 
Hourly Pay/Salary: 
Full Time/Part Time/PRN 


Position held and describe duties: 
Reason for Leaving? 
 
ADDITIONAL REFERENCES
 
Name: 
Relationship to applicant/Title: 
Telephone (Home): 
Telephone (Work) 
Organization: 
Address: 
Name: 
Relationship to applicant/Title: 
Telephone (Home): 
Telephone (Work): 
Organization: 
Address: 
 
CRIMINAL/ABUSE HISTORY
 
Do you have a record of founded child or dependent adult abuse in this state or any other state? * 
If yes, please explain and give dates: 
Have you ever been convicted of a crime in this state or any other state? (You are not required to reveal records that have been expunged, sealed or impounded.) * 
If yes, please explain offense and identify the state in which the offense occurred, provide dates and final disposition. 
Have you ever been excluded from or been served with an exclusionary notice of any governmental programs, ie Medicare? * 
If yes, please explain and give dates: 
 
SIGNATURE
 

Greene County Medical Center operates 24-hours a day, seven days a week. Assignment of shifts, hospital units, days off and other conditions of employment are generally made on basis of availability, tenure, and ability in each job classification. Each employee is required to comply with staffing assignments. As work changes occur within departments or hospital-wide, employees may be required to change shifts and/or days worked temporarily, or on a regular basis. By signing below, I certify that the answers and information set out above are true, accurate and complete to the best of my knowledge. I acknowledge that if any answer or information is not true, accurate or complete, I may not be hired, or if hired, I may be discharged.

I authorize the employer to investigate all statements contained in this application for employment to include criminal, child and dependent adult abuse information in accordance with Iowa Code, Section 134C.33, as well as my character and qualifications. I release the employer from all liability for actions performed in good faith and without malice in connection with evaluation of my application. I authorize my prior employers, references, and others with information regarding my work, educational history or my character, to provide the employer with all information requested and to cooperate fully with the investigation of my character and qualifications. I agree to cooperate in such an investigation, and release from all liability and/or responsibility all persons, companies, or corporations supplying such information.

I understand that if I am offered employment, the offer is contingent upon receipt of satisfactory employment references, acceptable criminal/abuse/compliance background information, a drug test (urinalysis), favorable health evaluation and a physical examination which may include proof of immunizations or be immunized for MMR2 (measles, mumps, rubella); Hepatitis B & Tdap, TB skin test, tetanus booster and/or evaluation using a physical capacity profile system.

I understand that this application is not a contract of employment. I understand that Iowa recognizes an at-will relationship between employee and employer. If hired, my employment and compensation can be terminated at will, with or without a showing of cause, and with or without notice by myself or my employer. I understand that nothing written or said will change my at-will employment status. I agree that if employed, I will abide by all policies, procedures, rules, and regulations established. I acknowledge that information contained in the official employee record is shared with authorized individuals within Greene County Medical Center.

I understand that if I am hired, I will be required to identify a financial institution into which my payroll check will be electronically deposited each pay period. I understand that if I am hired and I drive for Greene County Medical Center I will be required to have the appropriate current and unrestricted license. I may be required to furnish proof of my driving record as part of my application and may be required to release my driving record annually thereafter.

I have read the Greene County Medical Center Employee Standards listed on the website. I choose to be associated with an organization that values its customers by asking employees to meet such standards.

Greene County Medical Center seeks to provide a healthy, comfortable, and productive work and health care environment. In the event I am hired as an employee of Greene County Medical Center I acknowledge and agree to abide by Greene County Medical Center's Tobacco-Free Environment Policy. I understand that smoking or any tobacco use is strictly prohibited during working hours and I am not allowed to come to work smelling of tobacco. Tobacco us is prohibited anywhere on the Greene County Medical Center campus and within a one block radius. Greene County Medical Center is in compliance with the Smokefree Air Act of Iowa effective July 1, 2008.

Name: * 
Date: *    (mm/dd/yyyy)