Print Job Application Application for Employment Equal access to programs, services, and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department. NOTE - This application must be completed in it's entirety in one setting. Step 1 of 4 25% Position(s) Applied For:*Date of Application:* Name* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Mobile/Beeper/Other Phone:Email* Resume UploadAccepted file types: pdf.Upload a PDF of your resume, or email it to email@example.comAre you legally eligible for employment in this country?*YesNoDate available for work? What is your desired salary range?Employment Desired?Full TimePart TimeEmployment Desired?Full TimePart TimeUnit Interest (RNs Only) : Telemetry Intermediate Intensive Care OR Cath Lab Shift First Second Have you ever pled “guilty” or been convicted of a crime?YesNoAnswering “yes” to these questions does not constitute an automatic bar to employment. Factors such as date of offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.If yes, please provide date(s) and details How did you hear about Kansas Heart?FamilyFriendNewspaper Employment History 1Start Date: End Date: Employer:Hours:Full TimePart TimePhoneStarting Job TitleFinal Job TitleAddress Street Address City ZIP Code Immediate Supervisor and Title:Email address:For reference checking purposes.Summarize work performed and Job Responsibilities May we contact for reference?YesNoLaterIf no, why not? Reason for leaving: Starting Salary/Hourly RateFinal Salary/Hourly RateEmployment History 2Start Date: End Date: Employer:Hours:Full TimePart TimePhoneStarting Job TitleFinal Job TitleAddress Street Address City ZIP Code Immediate Supervisor and Title:Email address:For reference checking purposes.Summarize work performed and Job Responsibilities May we contact for reference?YesNoLaterIf no, why not? Reason for leaving: Starting Salary/Hourly RateFinal Salary/Hourly Rate Licensing/Certificate(s) Skills and Qualifications Summarize any training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.Education HistoryHigh School Name and Location# of Years CompletedDid You Graduate?YesNoCourse of Study:College Name and Location# of Years CompletedDid You Graduate?YesNoCourse of Study:Vocational Name and Location# of Years CompletedDid You Graduate?YesNoCourse of Study:Other Name and Location# of Years CompletedDid You Graduate?YesNoCourse of Study:References:Name First Last PhoneNumber of Years KnownEmail AddressFor reference checking purposes.Name First Last PhoneNumber of Years KnownEmail AddressFor reference checking purposes.Name First Last PhoneNumber of Years KnownEmail AddressFor reference checking purposes.Name First Last PhoneNumber of Years KnownEmail AddressFor reference checking purposes. I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (1) cancel further consideration of this application, or (2) immediately discharge me from the employer’s service, whenever it is discovered. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering, and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any for employment. I understand this application remains current for only 6 months. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminated my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied, oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president. I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 form in this regard. I understand that it is the Company’s writ ten policy to test for controlled substances and, as such, the Company has the right to require employees to be drug free so that the Company can maintain a safe work environment. Therefore, I give my consent to allow the Company to take any necessary specimens to test for any controlled substances. I understand that any test is a condition of my employment. I authorize any physician, laboratory, hospital or medical professional retained by the Company to release the results of the test to the Company or any authorized person affiliated with the Company in accordance with the law. I release any such institution or person conducting the test, the Company and any authorized person affiliated with the Company form any liabilities that may result from this t est. If I refuse to comply with the written policy or the results of the test are positive, this may be grounds for the Company to deny or terminate my employment. DO NOT CHECK UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.* I certify that I have read, fully understand and accept all terms of the foregoing Applicant statement. Electonic SignaturePlease type your full name.