Loring Hospital is an Equal Opportunity Employer. All employees and applicants for employment will be treated without regard to race, creed, color, sex, pregnancy, religion, age (18 & older), national origin, gender identity, sexual orientation or disability.

Have you ever been employed by Loring Hospital? * Yes No

Check all forms of employment for which you are interested * Full Time Part Time Regular Temporary 1st Shift 2nd Shift 3rd Shift Weekends

Are you eligible, and able to provide valid proof of eligibility, to be legally employed in the United States? * Yes No

Are you able to perform the duties of the position for which you have applied, with or without reasonable accommodation? * Yes No

Do you have a record of founded child or dependent adult abuse or have you ever been convicted of a crime other than a simple misdemeanor offense relating to motor vehicles and laws of the road under chapter 321 or equivalent provisions, in this state or any other? *
Convictions will not necessarily preclude one from consideration of employment - omitting this data WILL preclude one from employment. Yes No

Have you ever been discharged from a job? * Yes No

Education

High School

Post Secondary (College or University)

Technical or Vocational School

Training Programs or Further Education

Currently taking courses? Yes No

Professional Licenses, Registrations and/or Certifications

References

Please list the names of three persons - who are NOT relatives or friends - we may contact to verify your qualifications for the position.

Reference #1

Reference #2

Reference #3

Experience

Give a complete record of all employment and reasons for periods unemployed during the past ten years. Start with most recent employment.

Business or Employer's Name Position Address City State Phone Number From (Month/Yr): To (Month/Yr) Supervisor's Name Reason for Leaving (please be specific)

May we contact for a reference? Yes No

Other

How did you hear about this position? * Newspaper Friend Walk-In IWD Website Loring Hospital Website Other

Are you fluent in any language other than english? Yes No

By entering my name, I am making an application for employment with Loring Hospital I have truthfully given full information covering questions included in this application form. I understand that any offer of employment with Loring Hospital is contingent upon satisfactory passing of the required physical examination and drug screen. I also understand that if any of the information is found to be false, it is grounds for disqualification or immediate dismissal.

In considering your application for employment, the facility may conduct a detailed and thorough investigation which may include but is not limited to a criminal record check, interviews, and inquiries of prior employers, coworkers, acquaintances, relatives, or friends.

I hereby give permission to Loring Hospital to consult with my previous employers, acquaintances and with other sources to verify the information contained herein, and to learn of my ability and integrity (except where specifically requested, under employment history section) for the purpose of securing any other information Loring Hospital may deem necessary. I hereby release them and their organization from all liability or any damage whatsoever resulting from issuing information concerning me.

I understand that this application is not a contract of employment. I understand that Iowa recognizes an "At-Will" relationship between employee and employer, and I understand that nothing written or said will change my "At-Will" employment status.

Loring Hospital Employment Application