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Employment Application

Use the form below to submit your application via email.

*Required Fields
PERSONAL
*First Name:
*Last Name:
*Social Security Number:
Middle Initial
*Present Address:
*City:
*State, *ZIP:
Have you been a resident of Arkansas for 5 years or more? Yes   No
if no, Where:  
Address:
City:
State, ZIP:
Any previous name(s)? Yes   No
If Yes, Identify all other names including maiden name
Home Telephone No.:
*Contact Telephone No.:
*E-Mail:
Best Time to Contact you:
Date available for work:
Are you applying for:  Full Time    Part Time 
Regular     Temporary
Shift Preference:        Days             Evenings  
Nights 
Position applied for:
Salary desired:
How were you refered to this facility:
*Relatives or Friends employed
in this facility:		 Yes   No
If Yes, Name:          
Department: 
Relationship:
*Have you ever been employed by this facility?  Yes   No
*Are you 18 years of age or older? Yes   No
Are you a U.S. Citizen or an alien legally authorized to work in the U.S? Yes   No
*Are you currently employed: Yes   No
May we contact your present employer? Yes   No

*Have you ever been convicted of, or plead guilty to, a crime other than misdemeanor traffic violations?
                                     
Yes  No

If Yes, which state(s), and explain: (you are not required to disclose any sealed or expunged criminal records.)
 


*Have you ever been involved in the substantiated abuse or neglect of children or adults under the laws of this or any other stated of the U.S.?

Yes  No

If Yes, which state(s), and explain: (you are not required to disclose any sealed or expunged criminal records.)
 


*Have you ever been sanctioned, cited, reported, or excluded from participation in medicare, medicaid, or any other healthcare related law or regulation?                                                                 

Yes   No

If Yes, which state(s), and explain: (you are not required to disclose any sealed or expunged criminal records.)

If your answer is "yes" to any of the above, you will not be automatically disqualified from employment consideration, except as required by state or federal law.

EDUCATION AND SKILLS
Name and Address Course of Study Did you graduate? Last Year Completed Degree/ Diploma
*High School: Yes   No
 
College: Yes   No
 
College:    Yes   No    
 

Other College or Special Courses (include Special Military Training Post Guate and Nursing

Area(s) of specialization or major interests:
List office skills including computer/software experience:
List Health Care, Business or Industrial Equipment operated:
Word Processing: Approx. WPM

PROFESSIONAL LICENSES

1. Currently Licensed

State:

  

 License of Registration EVER suspended, revoked or on probation?
Yes    No 

2. Currently  Registered

State:

 License of Registration EVER suspended, revoked or on probation?
Yes     No 

If Yes, please explain

PROFESSIONAL CERTIFICATIONS

1. Currently Certified
   Eligible for Certification

Type:
State:
Date:
Number:

 

2. Currently Certified
   Eligible for Certification

Type:
State:
Date:
Number:

Briefly describe duties acquired through military or volunteer service:
(include dates)

PREVIOUS EXPERIENCE
Provide information regarding previous employment beginning with most recent employer:
Job Title:
Employer:
Employer Phone No.:
Address:
Duties:
Start Date: (Month/Year)
Last Date: (Month/Year)
Reasons for leaving:

Job Title:
Employer:
EmployerPhone No.:
Address:
Duties:
Start Date: (Month/Year)
Last Date: (Month/Year)
Reasons for leaving:

Job Title:
Employer:
EmployerPhone No.:
Address:
Duties:
Start Date: (Month/Year)
Last Date: (Month/Year)
Reasons for leaving:

Please identify and explain any gaps in employment longer than 3 months:

List at least 3 references who are not relatives:
Name and Relationship Title Company Name/ Address Telephone
*
*
*
 

CAREFULLY READ THIS SECTION PRIOR TO SUBMITTING YOUR APPLICATION

I hereby affirm that the information provided on this application is true and complete. I understand that any false misleading representations or omissions made on the application or during the hiring process may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date.
I understand that I may be required to satisfactorily complete a drug screening as a condition of employment.
I hereby authorize persons, schools, my current employer (if applicable) and previous employers and other organizations to provide this facility and its affiliates with any requested information regarding my application or suitabliity for employment, and I completely release all such persons or entities from any and all liability related to the providing or use of such information.
I understand that my employment is at-will which means that I may terminated the employment relationship at any time and for any resaon with or without notice, and that the facility has the same right. I understand that no one has the authority to enter into any agreement contrary to the preceding sentence, except for a written agreement signed by an administrative representative of this facility and notarized.

 I Accept

 

 

 

 

 

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Serving Western Arkansas and Eastern Oklahoma
Mena Regional Health System
311 North Morrow Street
Mena, Arkansas 71953

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