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Coffey Health System Online Application

The questions found on this form are being asked to properly evaluate your ability and chance for success in the position for which you are applying. Every effort has been made to comply with the applicable federal law and laws of our state. We do not discriminate in employment on the basis of color, race, sex, religion, age, national origin, marital status, handicap, veteran status, or any other protected class. It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors.

 
 
Position(s) applied for: *
How did you learn of this opening?



If you answered newspaper, website, or referral, please specify the name(s)
Shifts you would be available to work (please mark all that apply)




 
Name *
 
Address *
 
City *
State
   
Zip Code *
 
Telephone(s) *
   
Email Address *
   
Social Security Number (Enter as XXX-XX-XXXX) *
 
Are you over 18 years of age? *
If no, state date of birth
 
Have you ever been employed by Coffey Health System? *
Reason separated
Were you employed by Coffey Health System under another name?
If yes, state previous name
 
Have you ever been convicted of a crime other than a traffic violation? *
If yes, explain. A conviction will not necessarily bar you from employment. Each conviction will be evaluated on its own merit.
List professional, trade, business, or civic activities and offices held. You may exclude those which indicate race, religion, color, sex, national origin, or ancestry.
 
Have you ever been discharged from a job? *
If yes, explain.
 
Have you any relatives employed by Coffey Health System? *
If yes, please state name(s) and CHS division(s).
 
Is there any reason why you would be unable to safely perform any of the duties of the positions for which you applied with or without reasonable accommodations? *
If yes, please explain.
 
Do you have the legal right to live and work in the United States? *
If non-citizen, indicate visa type, number, and expiration date.
EDUCATIONAL BACKGROUND
 
Did you graduate from high school? *
Name, address & Zip Code of high school
 
Did you graduate from college? *
Name, address & Zip Code of college or university
Course of study or degree(s)
Did you complete graduate school?
Name, address & Zip Code of graduate university
Degree
Have you completed a professional, vocational, technical, or business program?
Name, address & Zip Code of program
Course of study/certifications
Other educational degrees or certification programs
What special skills do you have?
Typing speed (WPM)
Please list all computer software programs with which you are proficient.
Professional Registration or Licensure
Expiration date
Additional information
 
Reference #1. Please include name, occupation, organization, phone, and address *
 
Reference #2. Please include name, occupation, organization, phone, and address *
EMPLOYMENT HISTORY
List your work experience for the past ten (10) years BEGINNING WITH YOUR MOST RECENT POSTION.
Employer #1 - Name, address, phone
Supervisor #1
Dates of employment #1 (mm/dd/year to mm/dd/year)
Job title #1
Job duties #1
 
Final salary #1 *
Salary Method #1


Status #1
What did you like or dislike about job #1?
Reason for leaving job #1
Employer #2 - Name, address, phone
Supervisor #2
Dates of employment #2 (mm/dd/year to mm/dd/year)
Job title #2
Job duties #2
 
Final salary #2. This is a required field. If no other jobs, please enter "NA." *
Salary Method #2


Status #2
What did you like or dislike about job #2?
Reason for leaving job #2
Employer #3 - Name, address, phone
Supervisor #3
Dates of employment #3 (mm/dd/year to mm/dd/year)
Job title #3
Job duties #3
 
Final salary #3. This is a required field. If no other jobs, please enter "NA." *
Salary Method #3


Status #3
What did you like or dislike about job #3?
Reason for leaving job #3
Employer #4 - Name, address, phone
Supervisor #4
Dates of employment #4 (mm/dd/year to mm/dd/year)
Job title #4
Job duties #4
 
Final salary #4. This is a required field. If no other jobs, please enter "NA." *
Salary Method #4


Status #4
What did you like or dislike about job #4?
Reason for leaving job #4
Employer #5 - Name, address, phone
Supervisor #5
Dates of employment #5 (mm/dd/year to mm/dd/year)
Job title #5
Job duties #5
 
Final salary #5. This is a required field. If no other jobs, please enter "NA." *
Salary Method #5


Status #5
What did you like or dislike about job #5?
Reason for leaving job #5
 
May we contact your current employer? *
 
Statement of Application *
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Statement of Application

The facts set forth in my application for employment are true and complete. False statements, answers or omissions on this application shall be sufficient cause for non-consideration for employment or for dismissal after employment. I also recognize that my employment is based on receipt of satisfactory information from former employers and references, and upon my ability to pass a physical examination. I herein authorize the administration for this institution to investigate, without liability, the information supplied by me in this application for employment including academic, occupational, health, police, and governmental records. I also authorize listed employers and references, without liability, to make full response to any inquiries by the administration of this institution in connection with this application for employment. Further, if employed, I agree to work the hours, days and shifts as scheduled. I will share weekend and holiday coverage. I will work in another department if requested to do so. I understand and agree that the terms, conditions, compensations, benefits, hours, schedule, and duration of my employment (whether set forth in the Employee Handbook or not) may be determined, changed or modified from time to time at the will of my employer without limitation or condition. I FURTHER CERTIFY THAT I HAVE READ THE FOREGOING PARAGRAPH AND KNOWINGLY MAKE THIS AUTHORIZATION.

Your application is valid for a period of six (6) months. If you wish to be considered thereafter, you must physically reapply for employment at the Human Resources Department.

 

Equal Employment Opportunity (EEO) Voluntary Self-identification Form 

Qualified applicants are considered for employment without regard to race, religion, sex, national origin, age, marital status, sexual orientation, veteran status, disability, or other protected characteristic.

The employer follows certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, the employer invites employees to voluntarily self-identify their race or ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.

This form will be kept in a confidential file separate from your application for employment.  Click here to complete.