Online Job Application Form | Memorial Hospital of Lafayette County

Online Job Application Form

To be considered for employment by Memorial Hospital of Lafayette County, please complete the online employment application form below and click the "Submit Application Form" at the bottom. If you have any questions, please call (608)776-4466.

Items marked with an asterisk (*) are required.

Applicant Information

First Name: *

Middle Name/Initial: *

Last Name: *

Street Address: *

City: *

State/Province: *

Zip/Postal Code: *

Telephone: *

E-mail Address:

Date Available: *

Desired Salary:

Position Applied For: *

Are you a citizen of the United States: *

Yes

No

If no, are you authorized to work in the U.S.?:

Yes

No

Have you ever worked for this hospital?: *

Yes

No

If so, when?:

Have you ever been convicted of a felony?: *

Yes

No

If yes, explain:

Education

High School

Name of High School: *

Address:

Start Date: *

End Date: *

Did you graduate?: *

Yes

No

Degree:

College or University

Name of College or University:

Address:

Start Date:

End Date:

Did you graduate?:

Yes

No

Degree:

Other Education

Name of Institution:

Address:

Start Date:

End Date:

Did you graduate?:

Yes

No

Degree:

References

Please list three professional references.

Reference #1

Full Name: *

Relationship: *

Company: *

Title/Position: *

Address: *

Telephone: *

Reference #2

Full Name: *

Relationship: *

Company: *

Title/Position: *

Address: *

Telephone: *

Reference #3

Full Name: *

Relationship: *

Company: *

Title/Position: *

Address: *

Telephone: *

Previous Employment

First Employment Description

Company Name:

Address:

Title/Position:

Responsibilities:

Start Date:

End Date (If Applicable):

Starting Wage/Salary:

Ending Wage/Salary:

Reason for Leaving:

Supervisor's Name:

Telephone:

May we contact your supervisor for a reference?:

Yes

No

Second Employment Description

Company Name:

Address:

Title/Position:

Responsibilities:

Start Date:

End Date (If Applicable):

Starting Wage/Salary:

Ending Wage/Salary:

Reason for Leaving:

Supervisor's Name:

Telephone:

May we contact your supervisor for a reference?:

Yes

No

Third Employment Description

Company Name:

Address:

Title/Position:

Responsibilities:

Start Date:

End Date (If Applicable):

Starting Wage/Salary:

Ending Wage/Salary:

Reason for Leaving:

Supervisor's Name:

Telephone:

May we contact your supervisor for a reference?:

Yes

No

Registrations or Licenses

First Registration or License

Description:

State/Province:

Initial Date:

Expiration Date:

Second Registration or License

Description:

State/Province:

Initial Date:

Expiration Date:

Third Registration or License

Description:

State/Province:

Initial Date:

Expiration Date:

Date and Agreements

Date of Application: *

Agreement: *

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.