• Memorial Community Health Application for Employment

    Federal and State laws prohibit discrimination in employment because of sex, age, race, color, religion, creed, marital status, national origin, ancestry, disability or handicap.

  • GENERAL INFORMATION

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  • General Information continued...

  • If under 18 years of age, do you have parental permission?
  • Are you legally eligible for employment in the United States?
  • Have you ever been convicted of a felony?
  • Have you ever been sanctioned or been identified as an excluded provider for a federal or state health care program or have any such actions under investigation at this time?

  • EMPLOYMENT DESIRED

  • Division where you would like to work
  • Shift you can work (mark all that apply)
  • Have you previously worked for any division of Memorial Community Health?
  • Do you have a Professional License or Certificate?
  • Do you have a second Professional License or Certificate?
  • Has your professional license ever been revoked or placed on probation

  • EDUCATION

  • Diploma/Degree?

  • REFERENCES

    Please list three references - not employers or relatives

  • FORMER EMPLOYER # 1

    List your work experience starting with your most recent place of employment
  • If this is your current employer, may we contact them?

  • FORMER EMPLOYER #2

  • FORMER EMPLOYER #3

  • RESUME OR OTHER DOCUMENTS

    The following file types are supported - Microsoft Word (up to 2007), Adobe PDF, JPG and TIF. For other file types, please fax to 402.694.5024
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  • APPLICANT'S STATEMENT

    Please read the following carefully before submitting this application. Memorial Community Health, Inc. reserves the right to reject any application which is not fully completed.

  • If employed by Memorial Community Health, Inc., I agree to abide by compliance plans and its rules and regulations.

    The above information is complete and true to the best of my knowledge. I understand that discovery of misrepresentation or omission of facts herein will be cause for immediate dismissal. I authorize this facility to contact any and/or all of my references and/or previous employers for full information. I agree to take a physical examination, including a drug screen, at any time, at the request of this facility, and agree that the examining physician may disclose the findings to this facility or an authorized agent of this facility as it relates to the essential functions of my job only.

    I further understand that this is an application for employment and that no contract is being  offered. I understand that MCHI is an "at-will" employer. This means that except as protected by federal or state statute, my employment may be terminated by myself or by MCHI at any time. I understand that if I am employed, such employment is an indefinite period of time and that the company can change wage, benefits, and conditions at any time. Incomplete applications will not be accepted or processed.

    I understand that a set of Standards of Behavior has been developed by the employees of MCHI to establish specific behaviors that all employees are expected to practice while on duty. By incorporating these standards as a measure of overall work performance, MCHI makes it clear that employees are expected to adhere to and practice the standards of behavior outlined in the Personnel Manual and as stated on this application. I have read and understand the Standards of Behavior and, if offered employment by MCHI, I agree to comply with and practice the standards as outlined. (Please see PDF link to Behavior Standards)

    I certify that I have not been convicted of an offense that would preclude employment in a health care facility (hospital, nursing facility, clinic or other positions hired by Memorial Community Health, Inc.) and that I am not excluded from participation in a federal or state health care program.

    I understand the Memorial Community Health is a tobacco free organization and use of tobacco products is prohibited in or on all buildings, grounds, parking lots, and sidewalks adjacent to MCHI properties.

    I understand that Memorial Community Health, Inc operates 24 hours a day, seven days a week and that weekend work or temporary changes of shift may be required during employment.

    I HAVE READ AND AGREE TO THE ABOVE AND HEREBY CERTIFY THAT THE FACTS I PROVIDED IN MY EMPLOYMENT APPLICATION ARE TRUE AND COMPLETE.  

  • Date of Application
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