Employment Application

Kearny County Hospital


In considering your application for employment, the facility may conduct a detailed and through investigation which may include, but is not limited, to a criminal record check. Interviews or inquires of prior employers, co-workers, acquaintances, relatives or friends. 

FOR BEST RESULTS IN APPLYING ONLINE...     USE THE "NEWEST"GOOGLE CHROME OR FIREFOX BROWSER.

If you prefer to print this application, click on the link below, fill it out and turn it into our facility in person, or you may mail it to:

  • Kearny County Hospital
    Attn: HR Dept.
    500 E. Thorpe St.
    Lakin, KS 67860

If you prefer to download and email this application be sure to save it to a location you will remember. Once you have it saved you may fill in your information re-save it and email it to:

To Download and Save or Print the application click here.

Name:Required*
Address:Required*
Phone Number:Required*
Social Security Number:Required*
E-mail:
Date Available:Required*
Desired Salary:
Position Applying for:Required*
Are you a citizen of the United States?
In no, are you authorized to work in the U.S?
Have you ever worked for this company?
If yes, When?
Have you ever been convicted of, or plead guilty to a crime other than misdemeanor traffic violation?
Have you ever been involved in the substantiated abuse or neglect of children or adults under the laws of this or any other state in the United States?
If yes, which state(s), and explain: (You are not required to disclose any SEALED or EXPUNGED criminal records)
Have you been sanctioned, cited, reported, or excluded from participation in Medicare, Medicaid, or any other healthcare related law or regulation?

If your answer is "yes" to any of the above, you will not be automatically disqualified from employment consideration, except as required by state or federal law. 

The following is Kearny County Hospital's Mission Statement. Please take a few minutes and tell us what our mission statement means to you. "Kearny County Hospital is committed to providing quality, compassionate healthcare services for our community, to enrich the lives of our families, friends and neighbors."Required*

Education 

High School:
Attendance:
Did you Graduate?
Degree:
College:
Attendance:(1)
Degree:(1)
Other Education:
Attendance:(2)
Degree:(2)

Professional Licenses & Certifications

Type of License/Certification:
License or Registration:
State:
Date:
License/Certification Number:
Has your License or Certification ever been suspended, revoked or on probation?
If yes, Please Explain:
Type of License/Certification:(1)
License or Registration:(1)
State:(1)
Date:(1)
License/Certification Number:(1)
Has your License or Certification ever been suspended, revoked or on probation? (1)
If yes, Please Explain:(1)
Type of License/Certification:(2)
License or Registration:(2)
State:(2)
Date:(2)
License/Certification Number:(2)
Has your License or Certification ever been suspended, revoked or on probation? (2)
If yes, Please Explain:(2)

Previous Employment

Company:
Number:
Supervisor:
Job Title:
Salary:
Responsibilities:
Years Employed:
Reason for Leaving:
May we contact your previous supervisor for a reference?
Company:(1)
Number:(1)
Supervisor:(1)
Job Title:(1)
Salary:(1)
Responsibilities:(1)
Years Employed:(1)
Reason for Leaving:(1)
May we contact your previous supervisor for a reference? (1)
Company:(2)
Number:(2)
Supervisor:(2)
Job Title:(2)
Salary:(2)
Responsibilities:(2)
Years Employed:(2)
Reason for Leaving:(2)
May we contact your previous supervisor for a reference? (2)

References

Full Name:
Phone:
-
Relationship:
Company(1):
Address(1):
Full Name:(2)
Phone:(2)
-
Relationship:(2)
Company(2):
Address(2):
Full Name:(3)
Phone:(3)
-
Relationship:(3)
Company(3):
Address(3):

Language

Do you Speak/Read/Write any other languages then English?

Disclaimer and Signature

Carefully read this section prior to providing signature below:

I hereby affirm the information provided on this (and accompanying resume, if any) is true and complete. I understand that any false or misleading representations or omissions made on the application or during the hiring process may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date. 

I understand that employment may be conditioned upon successfully passing a medical examination and that I may be required to satisfactorily complete a drug screening as a condition of employment. 

I hereby authorize persons, schools, my current employer (if applicable) and previous employers and other organizations to provide this facility and its affiliates with any requested information regarding my application or suitability for employment, and I completely release all such persons or entities from any and all liability related to the providing or use of such information.

I understand that my employment is at-will which means that I may terminate the employment relationship at any time and for any reason with or without notice, and that the facility has the same right. I understand that no one has the authority to enter into any agreement contrary to the preceding sentence, except for a written agreement signed by an administrative of this facility and notarized.

Signature:
Date Signed:
Please attach your Resume/Cover Letter:
Text:
500 E Thorpe St, Lakin, KS 67860, 620-355-7111