An Equal Opportunity Employer


Instructions: Please complete every part of this application. If there is a question that does not apply to you, mark 'N/A'. Do not leave any question unanswered. Any false, misleading, or incomplete responses may result in disqualification for hire or immediate dismissal from employment.


*Note: A conviction record will not necessarily disqualify an applicant from employment. The circumstances of the conviction will be considered in relation to the nature and duties of the job for which application is made.
I hereby authorize Sheridan County Health Complex to obtain my criminal history record information, if any, to determine my fitness for employment.

Note: The law requires that you provide evidence and a sworn statement of your citizenship or work authorization if you are hired. Any offer of employment which you receive is contingent upon your providing the documentation and statement which we will request from you.
List your last three jobs, beginning with the most recent (you may omit dates for jobs held more than five years ago).

Job 1
Job 2
Job 3
Please list technical or trade school, college, and post-graduate education, if any:
If you are a veteran of the armed forces of the United States, please provide the following information:
Note: A less than honorable discharge will automatically disqualify you from employment.
Please list three personal references, other than prior employers or relatives, whom we can contact.
Reference 1
Reference 2
Reference 3
, hereby authorize the release and disclosure of employment information to Sheridan County Health Complex, Hoxie, Kansas, my prospective employer, concerning my employment with your organization. Upon written you may release:
  • Dates of employment
  • Pay level
  • Job description and duties
  • Wage history
  • Written employee evaluations, which were conducted prior to my separation from employment. (I understand that I may receive a copy, upon request.); and
  • Whether I was voluntarily or involuntarily released from service, and the reason for the separation.
By signing below, I certify that the 1) answers and information set out in this application are true and correct; 2) information submitted in my resume, if any, is true and correct; and 3) statements and information provided in my interview(s), if any, are true, accurate and complete to the best of my knowledge. I acknowledge that if any answer, statement or information is not true, accurate, correct or complete, I may not be hired, or if hired, I may be discharged. I voluntarily and knowingly authorize Sheridan County Health Complex to investigate all statements contained in this application for employment and to investigate my character and qualifications. I authorize my prior employers, references, and others with information regarding my work or educational history or my character, to provide Sheridan County Health Complex with all requested information and references, and to cooperate fully with the investigation of my character and qualifications.
I voluntarily and knowingly authorize any present employer or supervisor, past employer or supervisor, college, university of other institution of learning, administrator, private business, personal reference and/or other persons to give records or information they may have concerning my earnings history, health, character and employment records or any other information requested Sheridan County Health Complex. I authorize the investigation of all statements provided during the process of this application. I voluntarily and knowingly, unconditionally release any named or unnamed informant from any and all liability resulting from the furnishing of this information. This authorization shall be valid one year from the date signed and a photographic or faxed copy of the authorization shall be as valid as the original. I realize that as a condition of employment, I will be required to show original documentation of both identify and eligibility to work in the United States.
I understand that this application is not a contract of employment. I also acknowledge that no oral representations have been made, and that no one within Sheridan County Health Complex has the authority to make oral contracts of employment. If hired, my employment relationship with Sheridan County Health Complex is terminable at-will, with or without cause, by either myself or Sheridan County Health Complex.
I also understand that in the event I am offered a position with Sheridan County Health Complex, employment is conditioned upon my passing a possible background check, drug test, tuberculosis test and a physical examination which is administered by a health care professional selected by Sheridan County Health Complex, to which I hereby consent.

List all names used in the past: