Human Resources Department
1300 N. Main Street
Rushville, IN 46173
It is the policy of this facility to provide equal opportunity to persons regardless of race, religion,
age, gender, disability or any other classification in accordance with federal, state and local        
statutes, regulations and ordinances.                                                                                       
www.rushmemorial.com
email:  HR@rushmemorial.com
Date
This application can be active as long as legally required.
Last Name                                    First Name                                  Middle Initial
   
Are You At Least 18 Years Old?

Social Security Number (secure)

Home Phone And Cell Phone

Present Address

Present City

Present State

Present Zip Code

E-Mail Address

Previous Address

Previous City

Previous State

Previous Zip

Current Open Position(s) for Which You Are Applying




Type of Position
Per Diem
Pool
Full Time
PRN
Part Time
Temporary
Shift

Weekend
Day
Night
Evening
Rotation
Salary Requirement
$
Are You Willing To Travel?

If overtime work is required periodically, does this pose a problem for you?
Date Available For Work

Are You Legally Authorized to Work in the U.S.?
Have you ever worked for this facility?
If yes, when and what position? Are you related to another facility employee?
How did you learn about this position?
State Employment
       Commission

Internet
Agency
Ad
Job Listing
School
Current Employee
Job Line
Other:

Are you able to perform the essential, job related functions of the position for which you are applying with or without reasonable accommodations?
Describe any accommodations necessary:

Have you been convicted of a crime and/or released from confinement following a conviction for any criminal offense?
Arrests or charges that have been expunged need not be disclosed.
If yes, give date, place and nature of each such conviction.

Are you presently charged with any violation of the law?
If yes, give date, place and nature of each such event:
Educational History
Type of School
Name of School

City, State
Check Last Year
Attended in School

Degree or Certificate
High School
School:
    City:
   State:
9   10   11   12
Graduated/GED?
Degree:
College
School:
    City:
   State:
1     2     3    4
Graduated?
Degree:
College
School:
    City:
   State:
1    2    3     4
Graduated?
Degree:
Graduate
School

School:
    City:
   State:
1    2     3    4
Graduated?
Degree:
Other
School:
    City:
   State:
1    2    3    4
Graduated?
Degree:
Other
School:
    City:
   State:
1    2    3    4
Graduated?
Degree:
List any professional licenses, registration or certification you possess
(Include Driver's License, if applicable)
Include Type, State Issued, Expiration Date and Number.
Indicate if any licenses have been revoked, suspended or placed on probation.
Also indicate if you are ineligible to become licensed or certified in your field. Please explain.

Clerical or other skills applicable to the position for which you are applying
Typing (WPM)              PBX
Proficient in Software: 
For which positions are you interested:
      
Other 

Work History Application for Employment
HR7940 Rev 07/02





From (MM/YYYY)
Mo.

Yr.

To (MM/YYYY)
Mo.

Yr.

Company

Phone No.

Immediate Supervisor

Salary
$
Address

May we contact them?

Name while employed

Job Title

PRN Full-Time
Part-Time # Hrs/Week
Reason for leaving

Nature of Duties







From (MM/YYYY)
Mo.

Yr.

To (MM/YYYY)
Mo.

Yr.

Company

Phone No.

Immediate Supervisor

Salary
$
Address

Name while employed

Job Title

PRN Full-Time
Part-Time # Hrs/Week
Reason for leaving

Nature of Duties







From (MM/YYYY)
Mo.

Yr.

To (MM/YYYY)
Mo.

Yr.

Company

Phone No.

Immediate Supervisor

Salary
$
Address

Name while employed

Job Title

PRN Full-Time
Part-Time # Hrs/Week
Reason for leaving

Nature of Duties







From (MM/YYYY)
Mo.

Yr.

To (MM/YYYY)
Mo.

Yr.

Company

Phone No.

Immediate Supervisor

Salary
$
Address

Name while employed

Job Title

PRN Full-Time
Part-Time # Hrs/Week
Reason for leaving

Nature of Duties

Professional References (Other than Relatives) Give references who have good knowledge of your work.
Name
Position
Address (Include City/State)
Phone - Work/Home
Number of
Years known




















Please Review and Acknowledge That You Understand The Following.
In making application for employment:
* I certified that the information in this application is true and complete for all practical purposes.  It may be verified by the facility or any affiliate.  Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the facility or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.

* I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable.  If such an investigative report is made, I understand that I will receive notice that such a report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.


* I UNDERSTAND AND AGREE THAT ANY EMPLOYEE HANDBOOK WHICH I MAY RECEIVE WILL NOT  CONSTITUTE AN EMPLOYMENT CONTRACT, BUT  WILL BE MERELY A GRATUITOUS STATEMENT OF  FACILITY POLICIES.

*
I understand that the facility reserves the right to require its employees to submit to blood tests or urinalyses for alcohol or drug screens, or to allow inspection of bags (including purses or briefcases) or parcels brought into  or taken out of the facility.  I understand that refusal to  submit to a urinalysis or blood test, when requested to  do so, may result in termination of my employment.

* Compliance with this facility's Substance Abuse Policy is  a condition of employment.  This hospital requires that  every newly hired employee be free of alcohol or drug  abuse.  Each offer of employment is contingent upon  successfully completing a urinalysis test/screen for  alcohol and drugs in accordance with hospital policy. Continued employment is also contingent upon  compliance with the hospitals Alcohol and Drug Abuse  Policy.

*I UNDERSTAND AND AGREE THAT IF I AM OFFERED  EMPLOYMENT BY THE FACILITY, MY EMPLOYMENT  WILL BE FOR NO DEFINITE TERM AND THAT EITHER  I, OR THE FACILITY WILL HAVE THE RIGHT TO  TERMINATE THE EMPLOYMENT RELATIONSHIP AT  ANY TIME, WITH OR WITHOUT CAUSE, AND WITH  OR WITHOUT NOTICE,  I ALSO UNDERSTAND THAT THIS STATUS CAN ONLY BE ALTERED BY A  WRITTEN CONTRACT OF EMPLOYMENT WHICH IS SPECIFIC AS TO ALL MATERIAL TERMS AND IS  SIGNED BY ME AND THE ADMINISTRATOR OF THE FACILITY.

Release:
 
I hereby authorize any prior employers to provide such  information concerning my employment with them as  may be requested, and also authorize the  Registrar/Placement Office of all educational institutions  attended to release an official copy of my transcript and,  if available, faculty appraisals.  I also authorize any  appropriate licensing board to release full information  concerning my licensure status and my licensure history.

I agree that I will settle any and all claims, disputes or controversies arising out of or relating to my application for employment, employment or termination of employment with the employer exclusively by final and binding arbitration and before a neutral Arbitrator and in accordance with the rules and procedures for employment disputes adopted by the employer.  Such claims shall include those that could be brought in a court of law under any applicable federal, state or local statutory or common law, such as the Age Discrimination in Employment Act, Title VII of the Civil Rights Act of 1964, as amended, including the amendments of the Civil Rights Act of 1991, the Americans with Disabilities Act, the Family and Medical Leave Act, state civil rights acts, the law of contract and the law of tort.
I have read and understand these conditions of employment. Yes
Applicant's full name

Date Prepared


By clicking the "Submit Application" button below,
I agree that all of the preceding questions
are answered truthfully and to the best
of my abilities.