location/publication where you saw our advertisement
name of employee that referred you

Employment Desired


High School

Technical, Vocational, Business or Military Training

College or University

Graduate School

Office Skills

Professional Licenses and/or Certifications


Please skip if this does not apply to you.

Employment Record

Present or Last Employer

Previous Employer

Previous Employer

Previous Employer

General Information

Please list, sequentially, all the names by which you have been known


List three professional references (no relatives) we may contact:




Names of friends or relatives employed by this facility:




Employment Understanding

Please read the following statements carefully before you submit this application.

"I HEREBY CERTIFY that the answers given by me to the above questions and statements are true and correct and hereby voluntarily authorize this Facility to contact references, past or present employers, persons, schools, law enforcement agencies and any other sources of information which may be relevant to my application for employment. Further, I release from all liability or responsibility all persons, companies or corporations supplying such information. I voluntarily grant this release to support my application for employment at Rusk County Memorial Hospital and agree to inform the Facility of any special concerns I may have related to information which may be discovered during this investigation. I further understand that all information and documents acquired by Rusk County Memorial Hospital will be maintained as confidential by the Facility, and that the Facility will not release such information to me. It is understood and agreed that any misrepresentation, false statement, or omissions by me in this Application will be sufficient reason for rejection of my application or for dismissal at any time during my employment, without liability to this Facility.

I further understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also understand that no representative of the Facility has the authority to enter into any agreement for employment for any specified period of time and that this Facility is not guaranteeing employment for anyone. No employment contract is created by virtue of my being hired by this Facility.

If employed, I agree to abide by all of the work and safety rules of the Facility. If employed, I will be required to complete an Employment Verification Form (I-9), and within three days show satisfactory evidence of identity and eligibility for employment. I agree to any and all pre-placement assessment(s) as may be deemed necessary by Rusk County Memorial Hospital, and further understand that my employment is contingent upon my completion of the Facility pre-placement assessment. I understand that this Facility is committed to maintaining a drug-free workplace. I am aware that the Facility may require a drug test as a part of the hiring process. Also, if employed, I realize that the Facility may conduct post-accident and reasonable suspicion drug and/or alcohol testing of its employees."

I have read, understand and agree to the above statements.


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