Greene County Medical Center Employment Application

Greene County Medical Center is an Equal Opportunity Employer. All employees and applicants for employment will be treated without regard to race, creed, color, sex, pregnancy, religion, age (18 & older), national origin, gender identity, sexual orientation or disability.

Last Name * First Name * Middle Initial Email * Phone Number * Alternate Phone Current Address * City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Previous Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Position(s) for which you are applying? * ARNP or PA- Family Medicine ClinicClinical Nurse Supervisor-AcuteCook-Full-timeExecutive AssistantFamily Medicine PhysicianFood Service Site Manager-AramarkMA/LPN/RN-Family Medicine ClinicPatient Access- Part-timePCT-Acute Care Part-timePRN- Patient AccessPRN-Food Service WorkerPRN-Patient TransporterRad Tech Remote Telehealth-BSW/LMSW/LISW- (fulltime) FRespiratory TherapistRN Acute 7A-7PRN Acute 7A-7PRN Acute 7P-7ARN- Infection PreventionOther If other, please specify position If yes, please give dates of employment If yes, please explain If yes, please explain Professional, trade or other organizations

Education

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High School

High School Name City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Number of Years Attended Degree or Diploma?

Post Secondary (College or University)

Post Secondary (College or University) Name City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Major/Area of Study Number of Years Attended Degree or Diploma?

Technical or Vocational School

Technical or Vocational School Name City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Major/Area of Study Number of Years Attended Degree or Diploma?

Training Programs or Further Education

Training Programs or Further Education City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Major/Area of Study Number of Years Attended Degree or Diploma?

Professional Licenses, Registrations and/or Certifications

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References

Please list the names of three persons - who are NOT relatives or friends - we may contact to verify your qualifications for the position.

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Reference #1

Name * Occupation and position * Organization * Phone *

Reference #2

Name * Occupation and position * Organization * Phone *

Reference #3

Name * Occupation and position * Organization * Phone *

Experience

Give a complete record of all employment and reasons for periods unemployed during the past ten years. Start with most recent employment.

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Other

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If other, please list What office machines or computer software programs can you use? Area of specialization or major interest If yes, please list Please list any other information you believe to be pertinent to your application

By entering my name, I am making an application for employment with Greene County Medical Center I have truthfully given full information covering questions included in this application form. I understand that any offer of employment with Greene County Medical Center is contingent upon satisfactory passing of the required physical examination and drug screen. I also understand that if any of the information is found to be false, it is grounds for disqualification or immediate dismissal.

I hereby give permission to Greene County Medical Center to consult with my previous employers, acquaintances and with other sources to verify the information contained herein, and to learn of my ability and integrity (except where specifically requested, under employment history section) for the purpose of securing any other information Greene County Medical Center may deem necessary. I hereby release them and their organization from all liability or any damage whatsoever resulting from issuing information concerning me.

I understand that this application is not a contract of employment. I understand that Iowa recognizes an "At-Will" relationship between employee and employer, and I understand that nothing written or said will change my "At-Will" employment status.

Applicant's Signature *