Employment Application

Wabash County Hospital is an equal employment opportunity employer. We comply with all applicable state and federal civil rights and equal employment laws and regulations.

While Wabash County Hospital and its affiliates make every attempt to ensure that the information contained within this site is accurate, we cannot guarantee that the information will always be correct, particularly within the employment section.

If it is necessary to check the accuracy of any employment listing, please contact:

Human Resources - Wabash County Hospital
710 North East Street
P.O. Box 548
Wabash, IN 46992-0548
(260) 569-2327 or (800) 346-2110 ext. 2327

Personal Information
First Name*
Last Name*
Middle
Present Address*
Street AddressAddress Line 2CityStateZip Code
Permanent Address
Street AddressAddress Line 2CityStateZip Code
Any Previous Names?*
- Yes
- No
If 'Yes', Identify ALL Other Names Including Maiden Name
Home Phone*
Mobile Phone
Email
Best time to contact you
Date available to work
Are you applying for
Salary Desired
How were you referred to us?
Do you have any relatives or friends employed in this facility?
- Yes
- No
If yes
Name Department Relationship
Have you ever been employed by this facility?
- Yes
- No
If so, when
Are You 18?
- Yes
- No
Long Range Occupational Goals
Have you ever been convicted of, or pleaded guilty to, a crime (excluding misdemeanor traffic violations)?*
- Yes
- No
If yes, please explain
Would you consider working weekends & holidays?
- Yes
- No
Rotating shifts?
- Yes
- No
On call?
- Yes
- No
Any shift?
- Yes
- No
Shift preference
- Days
- Evenings
- Nights
Are You a U.S Citizen or an Alien Legally Authorized to Work in the United States?*
- Yes
- No

Previous Experience
Begin With Most Recent Employer
Employer 1*
From*
To*
Job Title*
Salary*
Supervisor Name*
Phone*
Address*
Duties*
Reason for Leaving*
Employer 2
From
To
Job Title
Salary
Supervisor Name
Phone
Address
Duties
Reason for Leaving*
Employer 3
From
To
Job Title
Salary
Supervisor Name
Phone
Address
Duties
Reason for Leaving*
Employer 4
From
To
Job Title
Salary
Supervisor Name
Phone
Address
Duties
Reason for Leaving*
Did You Serve in the U.S Armed Services?
- Yes
- No
What Branch?
Where?
Briefly describe duties and skills acquired through military service. (Include Details)
Have You Volunteered Your Time or Services?
- Yes
- No
Where?
Briefly describe duties and skills acquired through volunteer service. (Include Details)
References
List Three (3) References Who Are Not Relatives or Employers
Name 1
Relationship
Title
Company Name
Address
Phone Number
Name 2
Relationship
Title
Company Name
Address
Phone Number
Name 3
Relationship
Title
Company Name
Address
Phone Number
Agreement
Please check and initial the appropriate spaces below. You will be asked to sign this application prior to interviewing.

I hereby affirm that the information provided on this application is true and complete. I understand that false or misleading representations or omissions made on the application or during the hiring process may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date. I understand that employment may be conditioned upon successfully passing a medical examination and that I may be required to satisfactorily complete a drug screening as a condition of employment.

I hereby authorize persons, schools, my current employer (if applicable) and previous employers and other organizations to provide this facility and its affiliates with any requested information regarding my application or suitability for employment, and I completely release all such persons or entities from any and all liability related to the providing or use of such information.

I understand that my employment is at-will which means that I may terminate the employment relationship at any time and for any reason with or without notice, and that the facility has the same right. I understand that no one has the authority to enter into any agreement contrary to the preceding sentence, except for a written agreement signed by an administrative representative of this facility and notarized.

Initials entered in the box below must match the name included in the first section of this application and indicate that you have read the above statement.
Please enter your initials to acknowledge your agreement to the above statement*
By marking the box below I am attesting to my agreement with the above statement.*
- Agree
Email
This field is for validation purposes and should be left unchanged.

Job:

Step 1 of 3

Personal Information

High School

College 1

College 2

Professional License 1

Professional License 2

Professional Certification 1

Professional License 2

Previous Experience

References

Agreement

Job Information: