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Online Application

 
First Name*
Middle Name
Last Name*
Address*
City*
State*
Zip Code*
Home Phone*
Cell Phone
Email Address*
Social Security
Positions Applying For*
Date of Application (ex: 01/01/2006)*
How did you learn about us?
Best Time to call?
Have you previously applied with Girard Medical Center? Yes  No
Have you been previously employed by Girard Medical Center? Yes  No
Have you been previously excluded from federal healthcare? Yes  No
Are you currently employed? Yes  No
May we contact your employer? Yes  No
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Yes  No
Date Available for Work
Salary Range
Are you available Full Time? Yes  No
Are you available Part Time? Yes  No
Part Time Shift?
Are you currently on "layoff" status and subject to recall? Yes  No
Have you ever been convicted of a crime for abuse, neglect, or missappropriating funds? Yes  No
High School
High School years completed
High School Diploma Yes  No
Vocational/Technical School
Vocational/Technical Course Of Study
Vocational/Technical years completed
Vocational/Technical Diploma Yes  No
College/University (undergraduate)
Course of Study
Years Completed
Diploma/Degree Yes  No
Graduate/Professional
Course of Study
Years Completed
Degree
Professional Licenses
Numbers
Authorized States
Previous Employer #1
Address
City
State
Zip Code
Date Employed From
Date Employed To
Job Title
Supervisor
Hourly Rate/Salary Start
Hourly Rate/Salary Finish
Work Performed


 
Previous Employer #2
Address
City
State
Zip Code
Date Employed From
Date Employed To
Job Title
Supervisor
Hourly Rate/Salary Start
Hourly Rate/Salary Finish
Work Performed 


 
Reference Name #1
Phone
Best Time to Call
Occupation
Reference Name #2
Phone
Best Time to Call
Occupation
Reference Name #3
Phone
Best Time to Call
Occupation

 

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Girard Medical Center 302 North Hospital Drive Girard, KS  66743

620-724-8291 Fax: 620-724-6332

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