CCH
Name
Are you at least 18 years old? (Drop down menu with text: Yes, No)—Please choose an option—NoYes
Your email
Current Address
Phone Number
Date of Birth
Social Security Number
Department —Please choose an option—Swing BedMedical Center of DimmittCountry View LivingWelsh RehabChronic Care ManagementClinical LaboratoryNursingDermatology/SkincareDiagnostic ImagingRespiratory Therapy
Position you are applying for
Type of position —Please choose an option—Full-timePart-timeTemporary
Shift —Please choose an option—DayEveningWeekendNight
Are you willing to work overtime if needed? —Please choose an option—NoYes
Requested Salary
Date available to work
Are you legally authorized to work in the U.S.? —Please choose an option—NoYes
Have you ever worked for Castro County Hospital District? —Please choose an option—NoYes
Are you related to another facility employee? —Please choose an option—NoYes
Are you currently excluded from participating in any federally funded healthcare program – including Medicare and Medicaid – and are you aware of any potential exclusion from a federally funded health program? —Please choose an option—NoYes
Are you able to perform the essential, job related functions of the position for which you are applying with or without reasonable accommadations? —Please choose an option—NoYes
Have you been convicted of a crime and/or released from confinement following a conviction for any criminal offense? —Please choose an option—NoYes
If yes, give date, place and nature of each such conviction:
Are you presently charged with any violation of the law? —Please choose an option—NoYes
High school name
High school City and State
Last year attended in school
Graduated/GED and year?
College Name
College school City and State
Graduated and year?
List any professional licenses, registrations or certifications you posses
Clerical or other skills applicable to the position for which you are applying
Job Title #1
From Date
To Date
Company Address
Company Name
Supervisor Name
Supervisor’s Phone
Job Duties
Reason for leaving
May we contact employer? —Please choose an option—YesNo
Job Title #2
Name and Relationship #1
Position
Years known
Address
Phone number
Typing your name below gives Castro County Hospital District permission to run a background check for employment. (Please type sign) Typing your name below gives Castro County Hospital District permission to run a background check for employment. (Please type sign)
Attach resume if applicable
