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Employment Application

APPLICATION FOR EMPLOYMENT
Butler County Health Care Center
An Equal Opportunity Employer

Instructions: Please print all information and complete every part of this application. If there is a question that does not apply to you, mark "N/A", do not leave any questions unanswered. Any false, misleading, or incomplete responses may result in disqualification for hire or immediate dismissal from employment.

Position

Position(s) applied for (1): *

Position(s) applied for (2):

Date you can start: *

How did you learn about this job?: *

Prior Employment

List your last four jobs, beginning with the most recent. (Omit dates for jobs held more than five years ago.)

Employer 1

Employer name/address/phone: *

Job Title: *

Duties: *

Start date: *

End date: *

Salary/Bonus: *

What you liked most about job: *

What you liked least about job: *

Reason for leaving: *

Employer 2

Please enter "N/A" in the Employer name/address/phone box if this section is not applicable.

Employer name/address/phone: *

Please enter NA if not applicable

Job Title:

Duties:

Start date:

End date:

Salary/Bonus:

What you liked most about job:

What you liked least about job:

Reason for leaving:

Employer 3

Please enter "N/A" in the Employer name/address/phone box if this section is not applicable.

Employer name/address/phone: *

Please enter NA if not applicable

Job Title:

Start date:

Duties:

End date:

Salary/Bonus:

What you liked most about job:

What you liked least about job:

Reason for leaving:

Employer 4

Please enter "N/A" in the Employer name/address/phone box if this section is not applicable.

Employer name/address/phone: *

Job Title:

Duties:

Start date:

End date:

Salary/Bonus:

What you liked most about job:

What you liked least about job:

Reason for leaving:

Education and Training

School/College 1

List any high school, technical or trade school, college, and post-graduate education, if any.

Name of School: *

Level Completed: *

Degree: *

Major/Subjects: *

School/College 2

List any high school, technical or trade school, college, and post-graduate education, if any. Please enter "N/A" in the School Name box if this section is not applicable.

Name of School: *

Level Completed:

Degree:

Major/Subjects:

School/College 3

List any high school, technical or trade school, college, and post-graduate education, if any. Please enter "N/A" in the School Name box if this section is not applicable.

Name of School: *

Level Completed:

Degree:

Major/Subjects:

School/College 4

List any high school, technical or trade school, college, and post-graduate education, if any. Please enter "N/A" in the School Name box if this section is not applicable.

Name of School: *

Level Completed:

Degree:

Major/Subjects:

School/College 5

List any high school, technical or trade school, college, and post-graduate education, if any. Please enter "N/A" in the School Name box if this section is not applicable.

Name of School: *

Level Completed:

Degree:

Major/Subjects:

Other Skills

Describe any computer, office machine, tool or equipment skills and proficiency level:

Describe any other special skills or qualifications which may help you in the position applied for:

Professional licenses:

List all professional licenses or certificates held, including any State license(s). Please list the license or certificate type, date issued, and license or certificate number.

List any relevant professional or business organizations to which you belong (optional):

Regulation Information

Have you been subject to sanctions or exclusions under the Medicare or Medicaid Programs and/or have you been convicted of violation of other laws?

Subject to sanctions or exclusions: *

Yes, as follows:

Sanction details:

References

Please list two professional references (previous or current co-workers, classmates, teachers, etc.) and one personal reference, other than prior employers or relatives, whom we can contact.

Reference 1

Name: *

Phone: *

How long have you known this person?: *

Occupation: *

Reference 2

Name: *

Phone: *

How long have you known this person?: *

Occupation: *

Reference 3

Name: *

Phone: *

How long have you known this person?: *

Occupation: *

Applicant Name: *

Resume:

If you would like to attach your resume to this application, click the Browse button to find your resume file on your computer, then Upload to attach it to the application.

Employment Application

Butler County Health Care Center • 372 S 9th Street • David City, NE 68632

phone: (402) 367-1200 • fax: (402) 367-1350