Culbertson Memorial Hospital
238 S. Congress
Rushville, IL 62681
Telephone: (217) 322-4321
Fax: (217) 322-2608

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Employment Opportunities > Online Application

This application cannot be partially completed and saved. Please have all work history and other information accessible before entering data. Once the application is complete, be certain to read the "Waiver" section at the bottom of the form. If in agreement with the terms of the waiver, select "I accept." Then select "Submit" at the bottom of the form.

Contact Information

Full Name:
Address:
City:
State:
Zip:
Phone:
Email:

Employment Desired

Specify the job/department you are seeking and date you can start:

Voluntary Information (Completion of gender/race information is strictly voluntary)

Gender:

Male Female

Race:

Caucasian		Hispanic		Asian
Black		Indian		Other

General Information

Do you have a valid drivers license? Yes No
If No, explain:
Have you received a high school diploma or GED? Yes No
Are you currently employed? Yes No
May we inquire with your employer? Yes No
Are you currently on "lay-off" status and subject to recall? Yes No
Are you at least 18 years of age? Yes No
Have you been convicted of committing a crime? Yes No Conviction will not necessarily disqualify an applicant.
If Yes, explain:
Are you a U. S. Citizen or an alien legally authorized to work in the United States? Yes No

Professional Licenses

Currently licensed		Eligible for license
Currently registered		Eligible for registration

Type:
State:
Date:
No.:

License or registration ever suspended, revoked or on probation? Yes No

If yes, explain:

Professional Certifications

Currently certified Eligible for certification

Type:
State:
Date:
No.:

Education

High School
Name of School
Location of School
Years Attended
Date Graduated

College
Name of School
Location of School
Years Attended
Date Graduated

Other Training
Name of School
Location of School
Years Attended
Date Graduated

Specify any specialized training, apprenticeship, skills and extra-curricular activities:

Describe any honors you have received:

State any additional information you feel may be helpful in considering your application:

List any special skills and qualifications (summarize special job-related skills and qualifications acquired from employment or other experience):

What languages do you speak fluently?

Employment Experience

Employer 1 (most recent employer)

Employer
Phone Number
Address
Job Title
Supervisor
Employment Began
Employment Ended
Hourly Rate Beginning
Hourly Rate Ending
Reason for Leaving
Work Performed

Employer 2

Employer
Phone Number
Address
Job Title
Supervisor
Employment Began
Employment Ended
Hourly Rate Beginning
Hourly Rate Ending
Reason for Leaving
Work Performed

Employer 3

Employer
Phone Number
Address
Job Title
Supervisor
Employment Began
Employment Ended
Hourly Rate Beginning
Hourly Rate Ending
Reason for Leaving
Work Performed

Employer 4

Employer
Phone Number
Address
Job Title
Supervisor
Employment Began
Employment Ended
Hourly Rate Beginning
Hourly Rate Ending
Reason for Leaving
Work Performed

References

Name
Phone Number
Address
Business
Years Known

Name
Phone Number
Address
Business
Years Known

Waiver and Release

I hereby affirm that the information provided on this application is true and complete. I understand that any false or misleading representation 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.

After you have read the above Waiver and Release, check one of the following buttons:

I accept the above written Waiver and Release
I do not accept the above written Waiver and Release

Culbertson Memorial Hospital
238 S. Congress
Rushville, IL 62681
Telephone: (217) 322-4321
Fax: (217) 322-2608