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Geary Community Hospital is an EEOC workplace that is committed to providing equal opportunities to all qualified applicants and employees. This policy applies to recruiting, hiring, job assignment, supervising, training, upgrading, transfers, compensation, promotion, education, and all other terms and conditions of employment. Geary Community Hospital does not illegally discriminate on the basis of sex, race, color, religion, age, national origin, ancestry, marital status, disability, or Veteran-Era/disabled veteran's status.


Date:
Position Applying For:
How did you hear about this job?
If other, please name:
Do you have any relatives employed by GCH?
If yes, please name:

APPLICANT INFORMATION
Title:
First Name:
Middle Initial:
Last Name:
Street Address:
City, State, Zip:
Home Phone
Alternate Phone:
Email Address:
Are you a Citizen of the United States?
If no, are you authorized to work in the United States?
Have you ever been employed by Geary Community Hospital?
If So, when?
Have you ever been convicted of a felony?
(This information is subject to verification by background check. A conviction record will not necessarily preclude employment.)
If yes, please explain:
Shifts Available:1st
2nd
3rd
Weekends
Any
Multiple
Date available to start:
Desired Salary:

CERTIFICATES/LICENSES/REGISTRATIONS (PBT, RRT, RCPII)
Current Certifications:
(CPR, ECLS, etc...)
Nursing License:
(Number & State)
Registrations:

EDUCATION HISTORY
High School:
Address: (street, city, & state)
Did you graduate?
College or Vo-Tech:
Address: (street, city, & state)
Did you graduate:

REFERENCES:
Please list three professional references.
Full Name:
Company:
Contact Phone Number:
Full Name:
Company:
Contact Phone Number:
Full Name:
Company:
Contact Phone Number

EMPLOYMENT HISTORY
Please list the most current employer first.
Company:
Address: (Street, City, State, Zip)
Phone Number:
Supervisor:
Job Title:
Ending Salary:
Employment Period:
Responsibilities:
Reason for leaving:
Company:
Address: (Street, City, State, Zip)
Phone Number:
Supervisor:
Job Title:
Ending Salary:
Employment Period:
Responsibilities:
Reason for Leaving:
Company:
Address: (Street, City, State, Zip)
Phone Number:
Supervisor:
Job Title:
Ending Salary:
Employment Period:
Responsibilities:
Reason for leaving:

COVER LETTER & RESUME
Upload your cover letter: (MS Word or pdf format only)
Upload your resume: (MS Word or pdf format only)

AUTHORIZATION & AGREEMENT - Please read carefully before signing.

This application will remain active for 60 days. If hired within this period, this form will be transferred to your individual personnel file. If not hired within 60 days, this application will no longer be active and reapplication for employment will be necessary to be considered for employment at Geary Community Hospital. Any misrepresentation or falsification of information or omission of facts will be cause for rejection of my application or dismissal from employment (if hired). If my application for employment is accepted, effected date of my employment will begin when I report for training or work. If I am hired, I agree to abide by all rules, policies, and performance standards of Geary Community Hospital. My employment is not guaranteed for any term and my employment may be terminated by myself or Geary Community Hospital without restrictions. No management official is authorized to make any oral assurance or promise of continued employment with Geary Community Hospital. All information in the application process is subject to verification. I authorize and consent to my current and prior employers, educational institutions, and persons or organizations named in this applications to release any information to Geary Community Hospital that may be required to make an employment decision. I certify that my answers are true and complete to the best of knowledge. If this application leads to employment I understand that false or misleading information in my application or interview will lead to my immediate release.

SIGNATURE: (First, Middle Initial, Last Name)
(By signing here I certify that I have read the Authorization and Agreement.)
Today's Date:

VOLUNTARY DEMOGRAPHICS SURVEY

Dear Applicant:

Geary Community Hospital is an Equal Opportunity Employer. Qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, ancestry, marital status, handicap, age or Vietnam Era/disabled veteran’s status.

We are asking for your voluntary participation in an application survey. Data gathered in this survey will be used for government reporting purposes only and will be kept confidential, separate from applicant records. Your employment opportunity will not be negatively impacted by your choice to participate or not.

Please fill out the survey below and submit it with your completed application.

Please fill out the survey below and submit it with your completed application.

Thank you for your cooperation.

Government agencies require periodic reports on the sex, ethnicity, disability and veteran status of applicants. This data is for analysis and EEO reporting only.
Date:
Name: (First, MI, Last)
Address: (Street, City, State, Zip)
Phone Number:
Position applied for:

Please Check all applicable boxes below:

White
Black or African American
Hispanic or Latino
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaskan Native
Two or more races

Male
Female

Vietnam Era Veteran
Disabled Veteran
Disabled

Once you have completed the above application, please press the button below.