Kansas Surgery & Recovery Center

Online Employment Application

 Date of Application:

Equal access to programs, services, and employment is available to all persons. Those applicants requiring reasonable accomodation to the application and/or interview process should notify a representative of the Human Resources Department.

Social Security Number: Positions Applying for:
Name: Last Name:
First Name:
Middle Initial: 		Home Phone Number:


If necessary, the best time to call you at home:


Address: Street:

City: State:  Zip: 		Date available for work:


Desired Salary Range:


Are you legally eligible for employment in this country?
May we contact you at work? If yes, work number and best time to call: If you are under 18 and it is required, can you furnish a work permit? If no, please explain:
Have you submitted an application here before? If yes, give date(s) and position(s): Have you ever been employed here before? If yes, give dates:
Type of employment desired: Full-time:                
Part-time:               
Temporary:             
Seasonal:               
Educational Co-op:   		Are you able to meet the attendance requirements of the position?

Will you relocate if the job requires it?		   


  
Will you work overtime if required? If no, please explain: Have you ever been bonded?   
Shifts available to work: Day:                       
Evening:                  
Night:                      		Have you ever pled "guilty", or "no contest" to, or been convicted of a crime? If yes, please provide date(s) and details.

Employment History:

Employer:      Phone Number:  
Address:
             
City:      
State:            Zip:   
Employed From:   To:
Starting hourly salary:   Final hourly salary:
Starting Job Title:   Ending Job Title:
Reason For Leaving:
Immediate Supervisor and Title:    May we contact for reference?
Summarize the type of work performed and responsibilities:
Employer:      Phone Number:  
Address:
             
City:      
State:            Zip:   
Employed From:   To:
Starting hourly salary:   Final hourly salary:
Starting Job Title:   Ending Job Title:
Reason For Leaving:
Immediate Supervisor and Title:    May we contact for reference?
Summarize the type of work performed and responsibilities:
Employer:      Phone Number:  
Address:
             
City:      
State:            Zip:   
Employed From:   To:
Starting hourly salary:   Final hourly salary:
Starting Job Title:   Ending Job Title:
Reason For Leaving:
Immediate Supervisor and Title:    May we contact for reference?
Summarize the type of work performed and responsibilities:

Educational Background

School:
Number of years completed:
Degree diploma:
GPA or class rank:
Major:
Minor: 		School:
Number of years completed:
Degree diploma:
GPA or class rank:
Major:
Minor: 		School:
Number of years completed:
Degree diploma:
GPA or class rank:
Major:
Minor:

References

Name:
Phone number:
Number of years known: 		Name:
Phone number:
Number of years known: 		Name:
Phone number:
Number of years known:

Additional Information

List professional, trade, business, or civic associations and any offices held (exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve/national guard, or any other similarly protected status).


List special accomplishments, publications, awards, etc. (exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve/national guard, or any other similarly protected status).


List any additional information you would like us to consider.


I certify that all information I have provided in order to apply for and secure work with this employer is true, complete, and correct. I expressly authorize, without reservation, the employer, its representatives, employees, or agents to contact and obtain information from all references (personal or professional), employers, public agencies, licensing authorities, and educational institutions and to otherwise verify the accuracy of all information provided by me in this application. I hereby waive any and all rights and claims I may have regarding this employer, its agents, employees, or representatives for seeking, gathering, and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations, or organizations for furnishing such information about me.

Signature (type your name here if you are in agreement with the above statement):
Today's date:


Equal Opportunity and Affirmative Action survey information:

This survey will be separated from the application upon receipt and used for Equal Employment Opportunity review and Affirmative Action purposes only. Please do not include your name or make any marks which may identify you on this form. You are not required to furnish the information asked for this survey.

The information will not be provided to the person interviewing you and will not be a factor on determining your selection for employment. This form will be kept confidential and will only be used for statistical purposes.

Position(s) applying for:
Sex:
Race or ethnic group:
Today's date: