Application For Employment	ATTICA HOSPITAL DISTRICT #1 302 North Botkin Attica, Ks 67009 620-254-7253
Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the applications and/or interview process should notify a representative of the Human Resources Department. PLEASE PRINT Position(s) applied for_____________________Date of Application________ Name___________________________________________Social Security #____________                      Last                           First                Middle Address_________________________________________________________________                      Street                                       City                              State               Zip Code Telephone#(______) ________________Mobile/Beeper/other# (______) _____________ e-mail address__________________________________________________
If you are under 18, and it is required, can you furnish a work permit?	Yes           No
If no, please explain____________________________	_______________________________
Have you ever been employed here before?	Yes           No
If yes, give dates and position.	_________________________________
Are you legally eligible for employment in this country?	Yes           No
Date Available for work_________________________________	What is your desired salary range? $_____
Type of employment desired_____Full Time_____Part-Time	______Temporary____Seasonal
Are you able to meet the attendance requirements of the position?	Yes           No
Have you ever been convicted of any criminal violation of law, or are you now under pending investigation or charges of violation of criminal law?	Yes           No
If yes, please explain.__________________ _________________________________	_______________________________ _______________________________
Have you been the subject of any adverse action(s) by any duly authorized sanctioning or disciplinary agency for either conduct based or performance based actions?	Yes           No (Please circle one.)
Answering "yes" to these questions does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitaion and position applied for will be taken into account.
EMPLOYMENT HISTORY
Starting with your most recent employer, assignment or volunteer activities provide the following information. From (Month/Year) to (Month/Year) _______________________________ Employer                           Telephone# _____________________(______)______________ Starting job title/Final job title ________________________________ State nature of work performed and job responsibilities _________________________________________ _________________________________________