All fields marked with * are required
Kell West Regional Hospital Application For Employment
Last*
First*
Middle*
Street Address*
City, State, Zip*
Telephone Number
Alternate Number
E-Mail Address
Position*
Department
ER
Surgery
Med Surge
Laboratory
Business Office
Pharmacy
Radiology
Security
Housekeeping
Maintenance
Dietary
Other
Location
Kell West Hospital, Wichita Falls Texas
Holliday Clinic, Holliday Texas
Work Hours Shift Desired*
PRN (As Needed)
Part Time Any
Part Time Days
Part Time Evenings
Part Time Nights
Part Time Weekends
Full Time Any
Full Time Days
Full Time Evenings
Full Time Nights
Full Time Weekends
Have you ever been employed by Kell West Regional Hospital or any of its affiliates?*
Yes
No
Are you legally eligible for employment in the United States? (Proof required for employment)*
Yes
No
How were you referred to Kell West Regional Hospital?
Walk In
Employement Agency
Employee
Newspaper Ad
Other
Please list any friends you have working for Kell West.
Please list any family you have working at Kell West.
Have you ever been convicted of a crime greater than a class c misdemeanor?*
Yes
No
If yes please explain:
Do you have any physical, mental or medical impairment or disability that would limit your job performance in the job for which you are applying?*
Yes
No
If yes please explain:
Do you require any accomodations to perform the functions of the job for which you are applying?*
Yes
No
If yes please explain:
Education
High School Attended (Name location)*
Diploma Recieved?*
Yes
No
GED
College Attended (if applicable)
Degree Recieved
Business, Trade or Technical School
Diploma or Degree Recieved
Describe any specialized training you may have for the job you are applying for:
Honors Recieved:
Skills
Keyboard:
Shorthand:
10 Key
Others Not Listed
Membership in Professional Or Civic Organizations
Please provide as much detail as you can to any organization or group that you are a member of.
Military Service
Have you ever served in the U.S. Armed Forces?*
Yes
No
Describe the training you received relevant to the position for which you are applying:
Professional Certification
Do you hold any of the following licenses?
CNA
LV
RN
BSN
MSN
NP
PA
MD
If yes, please provide your current license number.
Do you have, or have you applied for, a Texas professional license, certificate or registration?
Yes
No
Current licensure and certifications
Has your professional license or registration ever been suspended or revoked in any state?
Yes
No
If yes please explain:
Personal References
Name 3 persons not related to you who can attest to your experience and qualifications:
Name, address, city, state, zip, phone
Name, address, city, state, zip, phone
Name, address, city, state, zip, phone
Employment Experience
Previous Employer
Address
Telephone
Job Title
Name of Supervisor
Employment Dates
Reason for leaving
May we contact your present employer?
Yes
No
Previous Employer
Address
Telephone
Job Title
Name of Supervisor
Employment Dates
Reason for leaving
Previous Employer
Address
Telephone
Job Title
Name of Supervisor
Employment dates
Reason for leaving
Previous Employer
Address
Telephone
Job title
Name of Supervisor
Employment dates
Reason for leaving
Previous Employer
Address
Telephone
Job title
Name of Supervisor
Dates of employment
Reason for leaving
The information that you provided in this employment application is true, correct and complete. I understand and agree that if employed by Kell West Regional Hospital that misrepresentation or omission of facts on this application is cause for denial of employment. I hereby authorize all parties listed herein to release any information concerning my previous employment, performance at schools (including transcripts) and medical information, which may be necessary to reach an employment decision. I understand that any offer of employment made to me by Kell West Regional Hospital is contingent upon my taking and passing a pre employment drug test. I also authorize Kell West Regional Hospital to perform a criminal background check to obtain criminal background information prior to employment in accordance with
The federal Fair Credit Reporting Act (FCRA)
.
I further understand that if I fail the drug test, or criminal background check, I will not be hired by Kell West Regional Hospital. I understand this application is not intended to be a contract of employment.
Please note that prospective employees who have been offered a position will only be given that position after sucessfull completion of a background and drug screen.
Type Your Name in the box to note that you have read the above and agree to the pre-employment drug screen and understand that I must pass a drug screen in order to be considerd for employment.
Type Your Name in the box to note that you have read the above and agree to the pre-employment background check and understand that I must pass a background check to be considered for employment.
Type your name in the box to signify a signature. We will have you sign a hard copy if you are called for an interview.
CANCEL and return to Kellwest.com
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