HODGEMAN COUNTY HEALTH CENTERAn Equal Opportunity Employer Instructions: If there is a question which does not apply to you, mark. “N/A”. Do not leave any question unanswered. Any false, misleading, or incomplete responses may result in disqualification for hire or immediate dismissal from employment.Positions Applied for *Today's Date *Date you can start How did you learn about this job? * PERSONAL INFORMATIONLast Name *First Name *Middle Name *Mailing Address *Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountryAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweHome Phone *Other Phone Email Address *Are you available *Full-TimePart-TimeTemporaryPlease describe any work schedule limitations: Have you applied for a job with us before? *YesNoIf yes, state date Have you been employed by us before? *YesNoIf yes, state date and jobs Do you have relatives employed by us? *YesNoif Yes, the following relatives Have you ever been convicted of a felony, or any crime relating to theft or dishonesty, or involving acts of violence? *YesNoif Yes Note A conviction record will not necessarily disqualify an applicant from employment: the circumstances of the conviction will be considered in relation to the nature and duties of the job applied forAre you a citizen of the United States, or specifically authorized to be employed in the United States? *YesNoNote The law requires that you provide evidence and a sworn statement of your citizenship or work authorization if you are hired. Any offer of employment which you received is contingent upon your providing the documentation and statement which we will request from you. PRIOR EMPLOYMENTNote List your last three jobs, beginning with the most recent (you may omit dates for jobs held more than five years ago).May we contact your current employer? *YesNoEmployer Name/Address/Phone Job Title Duties Dates Employed Salary $ Reason for leaving Employer Name/Address/Phone Job Title Duties Dates Employed Salary $ Reason for leaving Employer Name/Address/Phone Job Title Duties Dates Employed Salary $ Reason for leaving EDUCATION AND TRAININGName and location of high school *Graduated? *YesNoNote Please list technical or trade school, college, and post-graduate education, if any:School/College *Level Completed *Degree *Major Subjects * OTHER SKILLSDescribe any computer, tool, equipment or office machine skills and proficiency level *Describe any other special skills or qualifications which may help you in the position applied for: *List all licenses or certificates held, including state, license or certificate type, date issued, and license or certificate number: *List any relevant professional or business organizations to which you belong (Optional): VETERAN STATUSIf you are a veteran of the armed forces of the United States, please provide the following information: Military Branch Dates of Service Discharge Date Honorable Discharge? YesNoNote: A less than honorable discharge will not automatically disqualify you from employment. REFERENCESPlease list three personal references, other than prior employers or relative, whom we can contact. Name Phone How long known? Occupation Name Phone How long known? Occupation Name Phone How long known? Occupation Upload Resume MS Word Documents & PDF Files only VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank:
