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ONLINE APPLICATION FORM

Please fill out all fields to ensure that the form processes correctly. If a field is not applicable to you, enter "NA."

Personal Data

Contact Information:
Last Name  First Name  M.I.
Phone  Alt Phone
 
Street Address 
City  State  ZIP 
E-mail 
Other Names Under Which You Have Worked
Employment Eligibility
Are you a U.S. citizen or authorized to work in the U.S. on an unrestricted basis? Yes
No
Can you, after employment, submit proof of your legal right to work in the U.S.? Yes
No
Have you ever been convicted of or pled guilty to a crime?
If yes, please give the date, location, and disposition of your case:

Yes
No


Position Desired
Position(s) applied for
 
Salary Requirements
(optional)

I understand that applicants who do not meet the minimum qualifications of the position will not be considered for the position. Only those final candidates will be contacted.

I am interested in:
(check all that apply)
Full-time
Part-time
PRN
Names of relatives employed by the Boone County Health Center:
If an offer is extended, when you would be available to begin work?
How did you hear about us? Please check one:
Advertisement
Job Line
Direct Mail
Rehire
Education Program
 Posting/Walk-in
Employee Referral
Internet
Job Fair
Other


Employment History
Are you presently employed? Yes No
May we contact your present employer? Yes No
Most Recent Employer
Employer Name  From (mo/yr)  To (mo/yr) 
Address, City, State
 		 Starting Salary
 Ending Salary
Phone Job Title
Supervisor Name 
Supervisor Phone
Reason for Leaving
Other Employer
Employer Name From (mo/yr) To (mo/yr)
Address, City, State
 Starting Salary
 Ending Salary
Phone Job Title
Supervisor Name
Supervisor Phone
Reason for Leaving
Other Employer
Employer Name From (mo/yr) To (mo/yr)
Address, City, State
 Starting Salary
 Ending Salary
Phone Job Title
Supervisor Name
Supervisor Phone
Reason for Leaving
Other Employer
Employer Name From (mo/yr) To (mo/yr)
Address, City, State
 Starting Salary
 Ending Salary
Phone Job Title
Supervisor Name
Supervisor Phone
Reason for Leaving



Education and Training
Education (fill in all that apply)
School Name & Address No. of Years Course or Major Diploma/Degree
Professional and Technical Applicants Only (fill in all that apply)
Professional License No. Type of License Place of Issue Expiration Date

If you are licensed, has your license ever been suspended or revoked or are you currently involved in any proceeding that could affect your license or certification? Yes No
If yes, please give the date, location
and disposition of your case.



Professional References
Please do not list relatives
Name & Occupation Address Phone Number



Additional Information
Please use the space below for any additional information necessary to describe your full qualifications (i.e. specialty areas such as ICU, OB/GYN, special equipment, typing speed, computer software programs, etc.)
Do you speak, read, or write in any language other than English? Yes No
If yes, please describe



Please Read Carefully
I hereby certify that the answers to the foregoing questions are true to the best of my knowledge and agree to have any of the statements checked by Boone County Health Center unless I have indicated to the contrary.

I am aware that a more detailed investigation concerning background and credit may also be conducted, if applicable to the job for which I am applying, and I hereby authorize such an investigation.

I understand that employment is contingent upon satisfactory completion of reference checks and that, upon my written request, information on the nature and scope of an inquiry, if one is made, will be provided to me.

Should a job offer be made, I consent to taking a pre-placement physical examination and such future examinations as may be required. I understand that any job offer or my continuing employment, if hired, is contingent upon my being physically, mentally and medically able, with or without reasonable accomodation, to successfully perform the essential functions of my job. I agree that the results of my medical/health screen may be released to appropriate agencies in the event of a worker's compensation injury and/or dispute on payment of a medical claim. I understand that as part of my pre-placement physical examination, upon which any offer of employment is contingent, I will be required to successfully pass a drug screening test. The test will be administered at Boone County Health Center's expense, and will require me to provide a urine specimen for analysis. The urine specimen will be analyzed for the presence of marijuana, cocaine, phencyclidine (PCP), opiates, and amphetamines. Results of the drug test are confidential, and will not be disclosed to others without my specific written consent. My electronic signature below specifically signifies my consent to this pre-placement drug screening test.

I agree to wear or use all protective clothing or devices required by the facility and to comply with all safety policies and procedures.

I understand that nothing contained in this employment application is intended to lead to or create an employment contract between Boone County Health Center or any subsidiary or affiliate and myself which would in any way restrict the right of the company to terminate my employment at will.

I further understand and agree that the employment relationship that may result from my application will be employment-at-will, and either I or Boone County Health Center or any subsidiary or affiliate may terminate the relationship at any time.

I understand that any omission, misrepresentation or falsification can be grounds for refusal of employment. I further understand that, if employed, any false statements or misrepresentations herein or in conjunction with the application process may be cause for dismissal.


Applicant Certification
Please type your full name and e-mail address in the following boxes. By doing so and submitting this form to Boone County Health Center, you are agreeing to the terms and conditions stated above. Full Name
E-mail address




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