You must have JavaScript enabled to use this form. Current Personal Information Employment History Education & Training References Resume & Signature Preview Complete Indicates required field (Form 3 of 3)APPLICATION FOR EMPLOYMENTButler County HealthAn Equal Opportunity EmployerInstructions: 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 applied for (1) Position applied for (2) Date you can start How did you learn about this job? Personal Information First Name Middle Name Last Name Address Street Address City/Town State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP Code Phone Other Phone Email Are you available Full-time Part-time Temporary Please describe any work schedule limitations Have you been employed by us before? Yes No Please list dates and jobs at BCH Have you applied for a job with us before? Yes No Date Applied Do you have relatives employed by us? Yes No Relatives Employed Are you at least 18 years old? Yes No Are you at least 16 years old? Yes No Have you ever been convicted of abuse, neglect, a felony, or any crime relating to theft or dishonesty? Yes No Conviction Details 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 for. Are you lawfully employable? Yes No Are you lawfully employable in the United States either by virtue of citizenship or by having authorization form the INS and the Department of Labor? Note: 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 receive is contingent upon the documentation and statement which we will request from you. Do you have a valid Nebraska driver's license? Yes No
