Reedsburg Area Medical Center Employment Application

Position Information:

Job Title:

Have you applied at RAMC before? YesNo

Personal Data:

Last Name:	First:		Middle:
Street 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:
Social Security #:		Telephone:
Alternate Telephone:		Are you at least 18 years of age?		YesNo
Have you been employed at RAMC before?	Yes No	if yes, from: to:
Does an immediate family member or a person with whom you have a significant personal relationship work here?				YesNo
Do you have the legal right to work and remain in the United States? (Employment eligibility verification is required if hired)				YesNo
Have you ever been convicted of any law violation other than minor traffic violations? You must include all felonies and misdemeanor convictions including, but not limited to, disorderly conduct convictions or other non-criminal convictions which resulted in a fine. (A criminal records check will be conducted on all new employees prior to the first day of employment.)				Yes No
If yes, please describe and indicate date(s). (A conviction record will not necessarily disqualify you from employment consideration. A background check is required prior to employment.)

Availability:

Check all that apply.

Over 20 hours per week (Benefit Eligible) Under 20 hours per week Per Diem (no regular schedule)

Day Shift (7:00 am -7:00 pm) P.M. Shift (3:00 pm -11:00 pm) Night Shift (7:00 pm -7:00 am) Weekends

Are you able to rotate shifts?		YesNo
Hospital employees occasionally work more than 8 hours per day and most positions work some holidays. Are you able to meet this requirement?							YesNo

Education:

	Name of School	Address, City, State	Course of Study	Last Year Completed	Did you Graduate	Diploma or Degree
High School				1 2 3 4	Yes No
College				1 2 3 4	Yes No
Technical / Business				1 2 3 4	Yes No
Graduate				1 2 3 4	Yes No
Other				1 2 3 4	Yes No

List your experience with computers and other office equipment:

Please list any additional experiences, skills and qualifications which relate to the job for which you are applying:

Professional Licenses, Accreditations, and/or Certification:

List professional licenses, certifications, or registrations below.

Are you professionally licensed, certified or registered with any professional group, association or society?							YesNo
Group:			License(Title/Number):				Expiration Date:
Group:			License(Title/Number):				Expiration Date:
CPR Certification?			YesNo	ACLS Certification?				YesNo

Work History:

List all current and prior employment. A resume is not a substitute for completing this section.

Current or Most Recent Employer
	Company Name:			Dates of Employment: From: To:
	Street 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:	Phone:
	Title:		Last Salary:	Full Time Part Time	Supervisor's Name:
	Reason for Leaving:		May we contact for a reference? YesNo		Your Name Then (if different)

Previous Employer
	Company Name:			Dates of Employment: From: To:
	Street 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:	Phone:
	Title:		Last Salary:	Full Time Part Time	Supervisor's Name:
	Reason for Leaving:		May we contact for a reference? YesNo		Your Name Then (if different)

Previous Employer
	Company Name:			Dates of Employment: From: To:
	Street 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:	Phone:
	Title:		Last Salary:	Full Time Part Time	Supervisor's Name:
	Reason for Leaving:		May we contact for a reference? YesNo		Your Name Then (if different)

Previous Employer
	Company Name:			Dates of Employment: From: To:
	Street 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:	Phone:
	Title:		Last Salary:	Full Time Part Time	Supervisor's Name:
	Reason for Leaving:		May we contact for a reference? YesNo		Your Name Then (if different)

Professional References:

(Examples: Current and former supervisors, professional colleagues, professors. Do not list relatives or friends.)

Name	Address	Phone	Occupation

Non-Discrimination

It is the policy of Reedsburg Area Medical Center to consider all applicants for employment without regard to age, race, color, creed, religion, disability, marital status, gender, sexual orientation, national origin, ancestry, arrest record, conviction record, veteran’s status, membership in the National Guard, state defense force or any other reserve component of he military forces of the United States or Wisconsin, or any other unlawful basis.

Applicant’s Consent & Authorization

I certify that the facts set forth in this application are true, correct and complete without misrepresentations or omissions of any kind whatsoever. I authorize investigation of the statements I have made in this application.

I am applying for employment with Reedsburg Area Medical Center. I hereby authorize and release from liability any and all persons (including any and all employers with whom I have been employed, schools that I have attended and organizations with which I have been connected) to release any and all information they have about me to Reedsburg Area Medical Center. This includes all of my personnel records with prior employers and any information about my performance during my employment with them and also includes all of my transcripts from any schools that I have attended. I hereby release all persons, companies, schools, and organizations (and all persons connected with them) who provide such information to Reedsburg Area Medical Center from any and all liability for any damage for giving this information.

This Authorization shall remain in effect for a period of one (1) year from the date which I sign it. A photocopy of this authorization may be used by Reedsburg Area Medical Center and shall be effective as the original. I understand that if any of the information I have provided is false or misleading or if there are any misrepresentations or omissions of any kind whatsoever, then Reedsburg Area Medical Center may deny me employment or terminate my employment, and I agree that Sauk Prairie Memorial Hospital & Clinics shall not be liable in any respect if it does so.

I also understand that my employment at Reedsburg Area Medical Center is contingent upon the satisfactory completion of a medical examination which may include drug and alcohol screens, an investigation of my work record and references, and a caregiver background check. I consent to a pre-employment medical examination and such future examinations as may be required by Reedsburg Area Medical Center, which may include drug and alcohol screens as required.

I understand that if I am employed by Reedsburg Area Medical Center, any such employment is not binding on either party for any specific period of time. I further understand that no representative of Reedsburg Area Medical Center, other that the Chief Executive Officer, has the authority to enter into any agreement of employment for any specified period of time. Any such agreement must be in writing and signed by the CEO. I understand that any other written or oral statement to the contrary, even if made by a supervisor, manager, or director of Reedsburg Area Medical Center is invalid and should not be relied upon. I understand that if employed I will be an employee-at-will and that either Reedsburg Area Medical Center or I may terminate that employment relationship at any time, for any reason, with or without notice.

Attach a resume

How Did You Hear About Us?

Employee Of Reedsburg Area Medical CenterNewspaper Job PostingInternet site RAMC WebsiteJournal/Magazine RadioJob Fair TelevisionUniversity/College Posting Other

Read carefully and acknowledge by approving with your name and date at the box at the bottom of the form

Statements True and Complete: I certify that my statements on this application are true and complete to the best of my knowledge. I am aware that misrepresentation or omission of facts called for on this form is cause for rejection of my application or immediate discharge from the organization's service.

Background Investigation: I voluntarily give RAMC permission to make a thorough investigation of my past employment and criminal record. I agree to cooperate in such investigation and release from all liability, all persons, corporations or entities supplying such information.

At Will Nature of Employment: I understand and acknowledge that, unless otherwise defined by applicable law or collective bargaining agreement, any employment relationship with RAMC is of an "at will" nature, which means that I may resign at any time and RAMC may discharge me at any time with or without cause. This "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. If employed, I agree to work the hours, days and shifts as scheduled.

Examinations: I agree to take the pre-placement examination and such future physical examinations as may be required by RAMC. I understand that RAMC is committed to maintaining a drug-free workplace, and I understand that any offer of employment is contingent upon successful completion of the pre-employment examination.

Name:

Date:

RAMC is proud to be an equal opportunity employer.

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