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Email*
For which position are you applying?*
How did you learn of this job opening?*

Name of referring CHS employee
Are you able to work:*

Indicate your preferred place of employment. Mark all that apply.*


Name
First*
Middle
Last*
Maiden (optional)
Last 4 digits of social security number


Race / Ethnicity
Gender*
Please check ONE of the descriptions below corresponding to the ethnic group which you identify.


Address
Street Address*
City*
State / Province / Region*
Zip / Postal Code*


Phone Number
Contact Phone Number*
In emergency, notify*


General
Are you over 18 years of age?
If no, state birth date
Have you ever been employed by Coffey Health System?*
If yes, give date:
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If yes, under what name?
Please include full name.
Reason seperated
Do you have any relatives employed by Coffey Health System?
Are you currently employed?*
If yes, may we contact your present employer?*
Do you have a current and valid Kansas state drivers license?*
Have you been convicted of a crime which resulted in being listed by a state or federal agency as disbarred, excluded or otherwise ineligible?*
Have you ever been convicted of a crime other than a traffic violation?*
If yes to either above question, please explain. A conviction will not necessarily bar you from employment and will be evaluated on its own merit.
Have you ever been discharged from a job?*
If yes, explain.
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 exiration date.


Education
High School Name, City, and State*
Diploma / Degree*


Undergraduate / College
Undergraduate School Name, City, and State
Course of study
Degree completed


Graduate / Professional
Graduate School Name. City, and State
Graduate Diploma / Degree


Additional Information
Other Qualifiations, Professional Registration or Licensure
Specialized Skills
Equipment you've operated


Employment Experience
Employer #1 (starting with most recent)*
Employer #1 Address (Street, City, State, Zip)*
Employer #1 Telephone
Employer #1 Supervisor Name*
Employer #1 Start Date*
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Employer #1 End Date*
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Employer #1 Starting Hourly Wage / Salary*
Employer #1 Final Hourly Wage / Salary*
Employer #1 Work Performed*
Employer #1 Reason for Leaving*


Employer #2
Employer #2 Address (Street, City, State, Zip)
Employer #2 Telephone
Employer #2 Supervisor Name
Employer #2 Start Date
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Employer #2 End Date
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Employer #2 Starting Hourly Wage / Salary
Employer #2 Final Hourly Wage / Salary
Employer #2 Work Performed
Employer #2 Reason for Leaving


Employer #3
Employer #3 Address (Street, City, State, Zip)
Employer #3 Telephone
Employer #3 Supervisor Name
Employer #3 Start Date
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Employer #3 End Date
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Employer #3 Starting Hourly Wage / Salary
Employer #3 Final Hourly Wage / Salary
Employer #3 Work Performed
Employer #3 Reason for Leaving


List professional, trade, business or civic activities and offices held.


References
Reference #1 Name*
Reference #1 Occupation*
Reference #1 Address*
Reference #1 Telephone*


Reference #2 Name*
Reference #2 Occupation*
Reference 2 Address*
Reference #2 Telephone*


Applicant's Statement
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 my ability to pass pre-employment screenings. 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 the 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 BY SETTING FORTH MY SIGNATURE.
This application for employment shall be considered active for a period of time not to exceed 90 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.
In the event of employment, I understand that false or misleading information given in my application or interview may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.
Agree / Disagree*
(By checking "I AGREE", I verify the above "APPLICATION'S STATEMENT" is true.)
Signature*
Date*
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Have you been excluded from participation in Medicaid/Medicare because of fraud conviction?
UserEmailAddress*
 
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