EMPLOYMENT APPLICATION
* Denotes a required field
*Position:
*Name:
*Home Phone:
Business Phone:
*E.Mail Address:
*Street Address:
*City:
*State/ZIP:
*Are You a U.S. Citizen: Yes
No
If no, Permanent Residency or Work Permit Number:
Shift Desired:
Full Time
Day Shift
As Needed
Part Time
Evening Shift		 Temporary
Night Shift
Summer
Any
*Minimum Salary Desired:
*Date Available:
Referred By:
Employee
Internet
Newspaper
Physician
School
 Recruiting Fair
Walk In
Radio / TV
Other
If Other, Specify:
*Have You Ever Been Employed By Mobridge Regional Hospital and Clinics: Yes
No
If Yes Where:
Are You 18 Years or Older: Yes
No
If No What Is Your Age:
Have You Attended School or Been Employed Under Another Name: Yes
No
If Yes, What Name:
EDUCATION AND TRAINING
List Formal Schooling:
List Any Military Experience Which May Be Related To The Job For Which You Are Applying:
Graduated from High School? Yes No
CLERICAL SKILLS
Typing Speed:
Estimated:
Tested:
Date Tested:
Office Machines operated:
Dictating Machine
Computer
 Calculator
Computer Type / Software Used:
EMPLOYMENT HISTORY
Start with your present or last job
Company Name:
Position:
Describe Duties:
Dates of Employment: from:

to:
Supervisor:
Phone:
Salary:
Reason For Leaving:
Company Name:
Position:
Describe Duties:
Dates of Employment: from:

to:
Supervisor:
Phone:
Salary:
Reason For Leaving:
Company Name:
Position:
Describe Duties:
Dates of Employment: from:

to:
Supervisor:
Phone:
Salary:
Reason For Leaving:
Company Name:
Position:
Describe Duties:
Dates of Employment: from:

to:
Supervisor:
Phone:
Salary:
Reason For Leaving:
Have You Ever Been Discharged or Forced to Resign From Any Position? Yes
No
If Yes, Explain:
*May Your Present Employer Be Contacted For Job References? Yes
No
*May Your Past Employer(s) Be Contacted For Job References? Yes
No
PROFESSIONAL REFERENCES
Name:
Present Title:
Phone:
Company Name & Address:
Name:
Present Title:
Phone:
Company Name & Address:
Name:
Present Title:
Phone:
Company Name & Address:
Name:
Present Title:
Phone:
Company Name & Address:
SPECIAL SKILLS AND QUALIFICATIONS
CRIMINAL RECORD
Have you ever pled "guilty" or "no contest" to, or been convicted of a crime? Yes
No

Answering yes, does not constitute an automatic bar to employment. Factors such as date of the offense, age at time of offense, seriousness and nature of violation, and rehabilitation, as well as position applied for will be taken into account.
If yes, please provide date(s) and details (you do not need to provide information regarding sealed, expunged, or statutorily eradicated convictions).
*Have you ever had any of the following adverse legal actions imposed by Medicare, Medicaid, or any other federal agency or program? Yes
No
If yes please specific dates:
Program Exclusion(s)


Administrative Sanction(s)


Suspension of Payment(s)


Civil Monetary Penalty(s)


Assessment(s)


Program Debarment(s)











Judgments under the False Claims Act Yes
No

If you answered "yes" to the above question, please provide a date of the legal actions imposed. If you do not understand these questions, ask someone in Human Resources for assistance.

Pursuant to an agreement reached with the Federal Government. Mobridge Regional Hospital may not employ any individual who has been suspended ,excluded, debarred, or in otherwise ineligible to participate in any federal reimbursement program.
RESUME UPLOAD
Click browse to upload your resume with this application. Please use .doc or .pdf formats. Resume files must be smaller than 4MB.
EMPLOYEE CERTIFICATION

I certify the information contained in this application is true and complete. I understand providing any false or misleading information, misrepresentation or willful omission of facts during the application or interview process may result in withdrawal from consideration for employment or my immediate discharge if already hired, regardless of when discovered. I authorize Mobridge Regional Hospital to investigate all statements in this application and to conduct a thorough investigation of my past employment, education, and job related activities. I indemnify Mobridge Regional Hospital against any liability, which may result from conducting such investigation. All employers, educational institutions, and references listed are hereby authorized to give Mobridge Regional Hospital any and all information regarding my employment and character are hereby released from any and all liability which may result from furnishing such information.

I understand this application is not a contract of employment and if hired, regardless of any oral representations to the contrary, the employment relationship between myself and Mobridge Regional Hospital is terminable-at-will such that both the hospital and I remain free to choose to end our work relationship at any time for any or no reason. I understand my employment is contingent upon a background check and passing the health assessment(pre-work screening), including a drug screen, relevant to the position applied for in this application or the position for which I may be selected and I agree to undergo that assessment. I understand the Health assessment will be conducted by a provider at the Mobridge Medical Clinic or satellite clinic of Mobridge Medical Clinic to determine whether I can preform the essential functions of the job. I further understand a drug or alcohol test may be required depending hospital policy.

I authorize Mobridge Regional Hospital to supply my employment record, in its sole discretion, in whole or in part, to any prospective employer, governmental agency, or other party with an interest which Mobridge Regional Hospital deems appropriate.

I agree that any personal property carried by me to and from Mobridge Regional Hospital premises may be inspected by Mobridge Regional Hospital's authorized personnel.

Our Voluntary Declaration is an optional form to fill out. If you choose to do so please mail to Mobridge Regional Hospital c/o Human Resources
PO Box 580 Mobridge, SD 57601

Our Consumer Report document is required for position consideration. Please mail to Mobridge Regional Hospital c/o Human Resources
PO Box 580 Mobridge, SD 57601

* I fully understand and agree to the above statement