West Custer County Medical Center | Custer County Clinic

Personal Information

Name*

First Middle Last

Present Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is your physical address different than your mailing address above?*

Yes
No

Present Physical Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number*

Email Address*

Employment Desired

Position for which you are applying*

Are you employed now?*

Yes
No

Have you ever applied to the West Custer County Hospital District before?*

Yes
No

Education

Education History*

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Name of School	Location of School	Number of Years Attended	Did You Graduate?	Major or Subjects Studied

General

Subjects of Special Study or Work

Special Skills

Former Employers

Hidden

Number of Employers

Employment History*

List your last four (4) employers, starting with the most recent.

Starting Date	Ending Date	Name of Employer	Address of Employer	Phone of Employer	Salary	Position	Reason for Leaving

References

Professional References*

Please provide four (4) professional references. May substitute two (2) personal references.

First Name	Last Name	Company Name	Phone Number	Relationship to You

Consent and Agreement

I certify that all of the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected or, if I am employed at the time of discovery, my employment may be terminated.

In consideration of my employment, I agree to conform to the company's rules and regulations and, I agree that my employment and compensation can be terminated with or without cause and with or without notice at any time at either my or the West Custer County Hospital District options. I also understand and agree that the terms and conditions of my employment may be changed with or without cause and with or without notice at any time by the West Custer County Hospital District. I understand that no company representative, other than it's administrator, and then

You must agree to the above statement before submitting this application*

I understand and agree to the above statement

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