2026 Cimarron Memorial Job APPLICATION Form

2026 Cimarron Memorial Job APPLICATION Form

Job Application

Cimarron Memorial Hospital
Personal Information
Full Name

First NameMiddle NameLast Name
Address

P.O. Box

Physical Address [include apt #, if applicable]

CityState

Zip Code
Social Security Number
Date of Birth

MonthDayYear
Date
Primary Phone Number
Format: (000) 000-0000.
Secondary Phone Number
Format: (000) 000-0000.
Email you check regularly
example@example.com
Job/Position Applying For
Department
Shift applying for [if applicable]
Hours Available to Work
Days Available to Work
Have you ever worked for Cimarron Memorial Hospital?
approximate year(s)
If so, who was your supervisor?
Have you ever been discharged or asked to resign from a job?
If yes, please explain:
Record of Education
High School or GED
Name
City
State
Year Graduated
College/University
Name
City
State
Degree Earned
Year Graduated
Continuing Education

Are you currently enrolled in any classes (that we should take into consideration when creating schedules)?
Name
City
State
Degree/Certification enrolled in
Estimated Date of Completion

MonthDayYear
Date
Skills & Qualifications
Licenses, skills, trainings, awards
3 Personal References

[no relation to applicant]
Reference #1: Name & Address [P.O. Box, City, State/Zip Code]
City, State, ZIP
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
Reference #2: Name & Address [P.O. Box, City, State/Zip Code]
City, State, ZIP
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
Reference #3: Name & Address [P.O. Box, City, State/Zip Code]
City, State, ZIP
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
Special Circumstances
Are there any circumstances that might limit your ability to perform the job you are applying for?
Employment Verification Authorization
I, First Name Last Name authorize my previous employer(s) to release information pertaining to me while employed by them. I am aware that an employment reference check will be conducted by Cimarron Memorial, and I grant my permission for previous employers to release information to Cimarron Memorial.
Employee's Signature
Today's Date

MonthDayYear
Date
Current or Last place of Employment
Employer Name & Address [P.O. Box, City, State/Zip Code]
Street or PO box, city, state, ZIP code
Supervisor's Name and Title
Supervisor's email
Supervisor's Phone #
Your Job Title/Position
Your Status [Full-Time/Part-Time/PRN or Seasonal]
From date

MonthDayYear
Date
To date

MonthDayYear
Date
Reasons for leaving
Your Job Duties and Responsibilities
May we contact this employer?
Previous employment
Employer Name & Address [P.O. Box, City, State/Zip Code]
Street or PO box, city, state, ZIP code
Supervisor's Name and Title
Supervisor's Email
Supervisor's Phone #
Your Job Title/Position
Your Status [Full-Time/Part-Time/PRN or Seasonal]
From date

MonthDayYear
Date
To date

MonthDayYear
Date
Reasons for leaving
Your Job Duties and Responsibilities
May we contact this employer?
Use the space below to include previous employment for the past 7 years IF . . .

the above positions do not cover all employment for the past seven years
Employer Name & Address [P.O. Box, City, State/Zip Code]
Employer Name & Address [P.O. Box, City, State/Zip Code]
Notification of Criminal Arrest Check

Before employment at Cimarron Memorial Hospital, a Federal Criminal Background Check will be completed for each applicant. A check of the Office of Inspector General [OIG] Exception’s List and a check of the Oklahoma State Department of Health [OSDH] Nurse Aide Abuse Registry will also be completed. If an employee is found to have an outstanding debt with Cimarron Memorial Hospital and/or Clinic, a condition of employment will be signed by the employee to repay that debt.
Name

First NameMiddle NameLast Name
Maiden Last Name
All Married Names
Aliases
Social Security Number
Date of Birth

MonthDayYear
Date
Signature
Today's Date

MonthDayYear
Date
Cimarron Memorial does not discriminate in hiring or in any other decision on the basis of Race, Religion, Sex, Citizenship, National Origin, Ancestry, or on the basis of Age or Physical or Mental Disability unrelated to the ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.

I voluntarily give Cimarron Memorial the right to make a thorough investigation of my Past Employment & Activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies, or corporations supplying such information. I consent to take the Physical Examination and / or Screenings and future physical exams as may be required by Cimarron Memorial at such times and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physical exam which relates to the essential duties I would be required to perform. I understand that my employment is all at-will and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form. If employed, I will be required to complete an employment verification FORM I-9 and show satisfactory evidence of identity and eligibility for employment. I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future, if I am hired. I authorize the verification of any or all information listed above.
Signature
Full Name

First NameMiddle NameLast Name
Today's Date

MonthDayYear
Date
Should be Empty: