Online Application
Stewart Memorial Community Hospital is an equal opportunity employer. We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital status, or any other legally protected status.

Personal Information
Last Name *
Middle Initial *
First Name *
Phone *
Alternate Phone (Work or Cell)
Present Address *
City *
State *     Zip Code *
Permanent Address (If Different)
City
State
Zip Code
Email
  Are you 16 years of age or older?
  Yes No
  Have you ever filed an application with Stewart Memorial before?
  Yes No
If yes, give date
*
  Do you have any relatives working for this organization?
  Yes No
  If yes, name  
Relationship
  Are you currently employed?
  Yes No
  May we contact your present employer?
  Yes No
  Are there any other names under which your employment or educational records, references, and other information in the application may be verified? If so, list:
 
  Do you have a record of founded child or dependent adult abuse or have you ever been convicted of a crime, in this state or any other state?
  Yes No
If yes, please explain
 *
  Since reaching age 18, have you been convicted of a misdemeanor felony?
  Yes No
If yes, please explain
 *
  If you cannot be reached at the above numbers, where may we contact you?      
  Phone Number

Job Interests
Position(s) Applied For
Date of Application
Date Available
Salary Desired
Shift(s) available
 Full time Part time PRN Weekends
 

Education
School Name City/State Years Graduate Degree/ Diploma
College Yes No
College Yes No
College Yes No
College Yes No
High School/GED Yes No
Academic honors or special recognition (Exclude any information that may suggest race, religious creed, sex, marital status, age, color, national origin or physical handicap.)
Have you ever served as a volunteer?
Yes No
If yes, explain where and when you volunteered, what skills you used and jobs you performed.

Employment Experience
Failure to provide accurate and complete information may result in any offer of employment from Stewart Memorial being withdrawn or the termination of your employment if the information is discovered to be inaccurate and/or incomplete after you have become an employee.
Employer No. 1 (present or most recent employer)
Dates Employed
From
To
Name of Employer
Address
City
State
Zip Code
Phone Number
Your Position
Last Supervisor
Starting Salary
Ending Salary
Description of Work Performed
Reason for Leaving
May we contact this employer? Yes No
Employer No. 2
Dates Employed
From
To
Name of Employer
Address
City
State
Zip Code
Phone Number
Your Position
Last Supervisor
Starting Salary
Ending Salary
Description of Work Performed
Reason for Leaving
May we contact this employer? Yes No
Employer No. 3
Dates Employed
From
To
Name of Employer
Address
City
State
Zip Code
Phone Number
Your Position
Last Supervisor
Starting Salary
Ending Salary
Description of Work Performed
Reason for Leaving
May we contact this employer? Yes No
Employer No. 4
Dates Employed
From
To
Name of Employer
Address
City
State
Zip Code
Phone Number
Your Position
Last Supervisor
Starting Salary
Ending Salary
Description of Work Performed
Reason for Leaving
May we contact this employer? Yes No

Special Skills and Qualifications

If applicable, list all professional licensure information:
1) Profession
State Issues
Number
Expiration Date
2) Profession
State Issues
Number
Expiration Date
If applicable, list all professional registration/certification information:
1) Organization/Profession
Number
Expiration Date
2) Organization/Profession
Number
Expiration Date
If applicable, please list any professional credentials that you feel would relate to the position(s) for which you are applying (i.e. ACLS, BCLS, CPR):
Please list any technical skills or knowledge you possess which are related to the position(s) for which you are applying (i.e., equipment, software, medical terminology):
If applicable, present level of typing.
w.p.m.
Have you ever had any job-related training in the United States military? Yes No
Please state any additional information you believe would be important in considering your application.

Applicants Statement

 

1. I certify that the information provided in this application is true and accurate and I understand and agree that the falsification, misrepresentation or omission of any information in this application are grounds for withdrawal of a job offer or if I have been hired, grounds for termination.

2. I authorize release of employment, salary, education, and other related records to Stewart Memorial for the purpose of checking my references and verifying my employment and educational history. I understand and agree that if, in the judgment of Stewart Memorial, the results of the investigation are not satisfactory, any offer of employment made by Stewart Memorial may be withdrawn or my employment with Stewart Memorial may be terminated. I release all parties from liability for any damages which may result from the release of any information as a part of the employment verification process.

3. I understand Stewart Memorial may obtain a criminal, child and dependant adult abuse record check on applicants before employment.

4. I acknowledge that I understand Stewart Memorial has a policy of employment at will and if I am hired, my employment can be terminated with or without cause and with or without notice at any time at the option of either Stewart Memorial or myself.

5. All successful applicants must pass a physical examination prior to beginning employment at Stewart Memorial. I understand that an offer of employment is contingent upon my passing the medical examination before starting work. The examination may include a demonstration of my ability to perform the essential functions of the job. If the examination discloses conditions that prevent me from safely and successfully performing the essential functions of the job, Stewart Memorial will attemp to make accomodations that will enable me to work. If no reasonable accommodations can be found, or if such accommodations impose undue hardship on Stewart Memorial, the offer of employment will be withdrawn.

6. I understand that employment is contingent upon successful completion of a job-required licensure, certification, or registration exam, if applicable and not already completed.

7. In consideration of employment, I understant that emergency conditions may require me to temporarily work shifts other that the one for which I am applying and agree to such scheduling changes as directed by my department manager or administrator. If hired, I further agree to conform to all policies, rules and regulations of Stewart Memorial and understand that the terms, conditions, compensation, benefits, hours, schedule and duration of my employment (whether set forth in the employment handbook or not), may be determined, changed or modified from time to time at the will of Stewart Memorial without limitation or agreement.

8. I acknowledge that I have been advised that this application will remain active for on year from this date.

SUBMITTING THIS FORM IS EVIDENCE THAT I HAVE READ AND AGREE WITH THE ABOVE TERMS AND CONDITIONS, AND I ACKNOWLEDGE THAT MY SIGNATURE WILL BE REQUIRED ON THE PRINTED FORM DURING THE INTERVIEW PROCESS.

Yes No  *
 
  If you have any problems submitting this application, please call (712) 464-3171, or print and fax application to (712) 464-4121.