• Employment Application

    Edwards County Medical Center is an Equal Opportunity Employer.  We do not unlawfully discriminate against any applicant on the basis of race, color, religion, sex, national origin, age, sexual orientation, disability or any other category protected by federal, state or local law.

  • Applicant Information

  • Today's Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Date Available to Start*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Employment Preference*
  • Referral Source

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  • Are you authorized to work in the United States?*
  • Are you over the age of 18?*
  • If no, do you have an employment permit?*
  • Have you submitted an application to us before?*
  • Have you ever worked for this company?*
  • Do you have any relatives currently employed by Edwards County Hospital?*
  • In the last 10 years, have you ever been convicted of a crime other than a minor traffic offense?  (Conviction will not automatically disqualify you from employment)*
  • Have you ever been convicted of any criminal offense relating to health care?*
  • Have you ever been listed by a federal agency as debarred, excluded, or otherwise ineligible for participation in any federal health care program, either temporarily or permanently?*
  • If hired, will you be able to and submit to pass all pre-employment tests?*
  • Do you give permission to Edwards County Medical Center to do a complete background check?*
  • Do you have any commitments to another employer, which might affect your employment with us?*
  • Are you capable of satisfactorily performing the essential job duties of the position, with or without reasonable accommodation, for which you are applying?*

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  • Education

  • Did you attend additional college?
  • Did you attend additional college?

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  • References

    Please list at least three personal or professional references — not previous employers or relatives.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

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  • Previous Employment

  • Format: (000) 000-0000.
  • Start Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • End Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • May we contact your previous employer for a reference?*
  • Do you have additional previous employment?*
  • Format: (000) 000-0000.
  • Start Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • End Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • May we contact your previous employer for a reference?
  • Do you have additional previous employment?
  • Format: (000) 000-0000.
  • Start Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • End Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • May we contact your previous employer for a reference?

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  • Military Service

  • From
     - -
    2 digit month, 2 digit day, 4 digit year
  • To
     - -
    2 digit month, 2 digit day, 4 digit year

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  • Special Skills & Qualifications

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  • Disclaimer & Signature

  • I hereby declare that the information provided by me in this Application for Employment (and in any accompanying resume) is true, correct and complete to the best of my knowledge.  I authorize Edwards County Hospital (or its designee) to investigate my past and present employment, education and activities and verify all data provided by me on this application, on related papers and in interviews.  I authorize all individuals, schools and/or firms named herein (except my current employer, if so noted) to provide any information requested about me.  I release from all liability any persons, companies, corporations or educational institutions supplying such information.  I release Edwards County Hospital (or its designee) from any and all liability resulting from the verification of such information.  I understand that any false statement or material omission on this application, or on any supporting documents, shall be grounds for non-hire or discharge, regardless of when discovered by Edwards County Hospital.


    I understand that this employment application, or the granting of an interview, does not represent a contract of employment or a promise of future benefits by Edwards County Hospital.  I further understand that there is no guarantee that Edwards County Hospital will be able to place me with one of its clients.  If I am hired by Edwards County Hospital, I understand that my status will be that of an employee-at-will, meaning that I will have no contractual right, express or implied to remain in Edwards County Hospital’s employ.  I further understand that, if I am hired, my employment can be terminated, with or without cause and with or without notice at any time, at the option of Edwards County Hospital or me.  I also understand that no representative of Edwards County Hospital has the authority to enter into any oral agreement for employment for a specified period of time or to make an oral agreement contrary to the foregoing.


    I understand that Edwards County Hospital requires a physical examination as a condition of employment.


    I understand that if I am hired by Edwards County Hospital and my employment subsequently ends, Edwards County Hospital may provide information about my employment to persons in response to job reference requests, and I hereby consent to such disclosures.


    If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

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  • Today's Date*
     / /
    2 digit month, 2 digit day, 4 digit year

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