Sauk Prairie Memorial Hospital & Clinics
I want to...
Login | Register
On-line Application
Print Application.

As a registered user of our website, you may use your profile settings to store your information. After logging in, click on your name above and choose Manage Profile to enter your information. The Profile Properties you enter will automatically fill the corresponding fields in the application below. You may come back again and again without having to re-enter your information.
  
 
Sauk Prairie Memorial Hospital and Clincs Logo

Employment Application

 Website: www.spmh.org
Phone: (608) 643-7169
Fax: (608) 643-7275
TDD: (608) 643-7186


Position Information:

Job Title:
Have you applied at SPMHC before?

Personal Data:

Last Name: First: Middle:
Email:
Street Address:
City: State: Zip:
Social Security #: Telephone:
Alternate Telephone: Are you at least 18 years of age?
Have you been employed at SPMHC before? if yes, from: to:
If yes, Job Title:
Does an immediate family member or a person with whom you have a significant personal relationship work here? (SPMHC policy prohibits direct or indirect supervision of an employee by a person with such a relationship.)

Do you have the legal right to work and remain in the United States? (Employment eligibility verification is required if hired)

Have you ever been convicted of any law violation other than minor traffic violations? You must include all felonies and misdemeanor convictions including, but not limited to, disorderly conduct convictions or other non-criminal convictions which resulted in a fine. (A criminal records check will be conducted on all new employees prior to the first day of employment.)

If yes, please describe and indicate date(s). (A conviction record will not necessarily disqualify you from employment consideration. A background check is required prior to employment.)

Availability:

Check all that apply.




Are you able to rotate shifts?
Hospital employees occasionally work more than 8 hours per day and most positions work some holidays. Are you able to meet this requirement?

Education:

Name of School Address, City, State Course of Study Last Year Completed Did you Graduate Diploma or Degree
High School
College
Technical / Business
Graduate
Other
List your experience with computers and other office equipment:
Please list any additional experiences, skills and qualifications which relate to the job for which you are applying:

Professional Licenses, Accreditations, and/or Certification: List professional licenses, certifications, or registrations below.

License(Title): Expiration Date:
License(Title): Expiration Date:
CPR Certification? ACLS Certification?

Work History: List all current and prior employment. A resume is not a substitute for completing this section.

Current

or

Most Recent

Employer
Company Name:
 Dates of Employment:
From: To:
Street Address:
 City:
 State:
 Zip:
 Phone:
Title:
Last Salary:
 Supervisor's Name:
Job Responsibilities:
Reason for Leaving:
 May we contact for a reference?
Your Name Then (if different)

Previous

Employer
Company Name:
 Dates of Employment:
From: To:
Street Address:
 City:
 State:
 Zip:
 Phone:
Title:
Last Salary:
 Supervisor's Name:
Job Responsibilities:
Reason for Leaving:
 May we contact for a reference?
 Your Name Then (if different)

Previous

Employer
Company Name:
 Dates of Employment:
From: To:
:
 City:
 State:
 Zip:
 Phone:
Title:
Last Salary:
 Supervisor's Name:
Job Responsibilities:
Reason for Leaving:
 May we contact for a reference?
 Your Name Then (if different)

Previous

Employer
Company Name:
 Dates of Employment:
From: To:
Street Address:
 City:
 State:
 Zip:
 Phone:
Title:
Last Salary:
 Supervisor's Name:
Job Responsibilities:
Reason for Leaving:
 May we contact for a reference?
 Your Name Then (if different)

Professional References: (Examples: Current and former supervisors, professional colleagues, professors. Do not list relatives or friends.)

Name Address Phone Occupation

Non-Discrimination

It is the policy of Sauk Prairie Memorial Hospital & Clinics to consider all applicants for employment without regard to age, race, color, creed, religion, disability, marital status, gender, sexual orientation, national origin, ancestry, arrest record, conviction record, veteran’s status, membership in the National Guard, state defense force or any other reserve component of he military forces of the United States or Wisconsin, or any other unlawful basis.


Service Excellence Standards

I understand that I am responsible for knowing and adhering to the following standards.

SERVICE

Introduce yourself and describe what you will be doing.
Help visitors to their destination.
Ask “Is there anything else I can do for you?”
Explain delays.
Find a way to say “Yes” if possible; if the answer is “No”, explain why.
Go out of your way to make it happen.

COMMUNICATION

Smile!
Make eye contact.
Be an active and engaged listener.
Talk so your voice sounds like you’re smiling.
Say please and thank you in verbal and written communications.
Tell someone you’re sorry.
Strive for face-to-face interactions whenever possible.
Acknowledge others when entering a room or hallway.
Be polite on the phone/Vocera.
Even if you’re busy, be gracious and make time for people.
Assume others mean well. Don’t read negativity into things, ask questions instead.
Filter your thoughts before speaking.
Lower your voice.

ACCOUNTABILITY

Learn about other departments and the people who work there.
Stay informed and involved.
Assume there is something you can do; take ownership.

PROFESSIONALISM

Demonstrate an “I want to be here” attitude.
Ensure confidentiality.
Be constructive and offer solutions – not complaints.
Change your complaint to a request.
Come to work with a good attitude and work ethic.
Be optimistic and grateful.
Talk up and “sell” other departments.
Practice looking good – take good care of yourself.

RESPECT

Remember: every person counts.
Learn how to agree to disagree.
Be positive – avoid criticizing, condemning or complaining.
Respect what others bring to the table.
Be open to hearing both the good and the bad and sharing it.
Model respectful behavior regardless of “rank.”

TEAMWORK

Offer to help each other even if it’s “not your job.”
Ask your teammates if you can help them.
Be flexible.
Assume everyone is trying their best; don’t blame or point fingers.
Be part of a team.
Notice and celebrate success.
Catch others doing something good and thank them.

Applicant’s Consent & Authorization

I certify that the facts set forth in this application are true, correct and complete without misrepresentations or omissions of any kind whatsoever. I authorize investigation of the statements I have made in this application.

I am applying for employment with Sauk Prairie Memorial Hospital & Clinics. I hereby authorize and release from liability any and all persons (including any and all employers with whom I have been employed, schools that I have attended and organizations with which I have been connected) to release any and all information they have about me to Sauk Prairie Memorial Hospital & Clinics. This includes all of my personnel records with prior employers and any information about my performance during my employment with them and also includes all of my transcripts from any schools that I have attended. I hereby release all persons, companies, schools, and organizations (and all persons connected with them) who provide such information to Sauk Prairie Memorial Hospital & Clinics from any and all liability for any damage for giving this information.

This Authorization shall remain in effect for a period of one (1) year from the date which I sign it. A photocopy of this authorization may be used by Sauk Prairie Memorial Hospital & Clinics and shall be effective as the original. I understand that if any of the information I have provided is false or misleading or if there are any misrepresentations or omissions of any kind whatsoever, then Sauk Prairie Memorial Hospital & Clinics may deny me employment or terminate my employment, and I agree that Sauk Prairie Memorial Hospital & Clinics shall not be liable in any respect if it does so.

I also understand that my employment at Sauk Prairie Memorial Hospital & Clinics is contingent upon the satisfactory completion of a medical examination which may include drug and alcohol screens, an investigation of my work record and references, and a caregiver background check. I consent to a pre-employment medical examination and such future examinations as may be required by Sauk Prairie Memorial Hospital & Clinics, which may include drug and alcohol screens as required.

I understand that if I am employed by Sauk Prairie Memorial Hospital & Clinics, any such employment is not binding on either party for any specific period of time. I further understand that no representative of Sauk Prairie Memorial Hospital & Clinics, other that the Chief Executive Officer, has the authority to enter into any agreement of employment for any specified period of time. Any such agreement must be in writing and signed by the CEO. I understand that any other written or oral statement to the contrary, even if made by a supervisor, manager, or director of Sauk Prairie Memorial Hospital & Clinics is invalid and should not be relied upon. I understand that if employed I will be an employee-at-will and that either Sauk Prairie Memorial Hospital & Clinics or I may terminate that employment relationship at any time, for any reason, with or without notice.


Attach a resume

 Upload  

How Did You Hear About Us?


Information provided will be used for administrative purposes only.


Sex:
Race/Ethnicity:

Veteran Status:
Disability Status:

My typed name below shall have the same force and effect as my written signature.

Candidate's/Applicant's Signature:*

Date:*

SPMHC is proud to be an equal opportunity employer.

Submit
  
line
 
  
 
find us on Facebook