Employment Application

Registered Nurse Emergency Department 0.7 FTEView Job Details CCH is looking for a Registered Nurse on a part-time basis (0.7 FTE 28 hours per week) to work in our Emergency Department. This position will be  Day/PM and will be a combination of 8 and 12 hour shifts. This individual must be a professional who provides leadership for other members of the patient care team. The RN performs patient age-specific physical, psychological, and social assessments, formulates a nursing diagnosis and then develops a plan of care, which includes individualized treatment strategies......
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Employment Information
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Please answer all of the following questions.
Are you at least 18 years of age and legally eligible to work for our company in the United States?
If you are under 18 years of age, can you provide required proof of your eligibility to work?
Are you currently bound by a noncompetition, confidentiality or trade secret agreement?
If yes, please explain.
Have you ever been discharged or asked to resign from a job?
If yes, please explain.
Have you ever been convicted of or pled guilty to a felony or crime other than a minor traffic citation?
If yes, please explain.
Employment History
Are you currently employed?
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Job-related Skills
Please use this space to list any special skills you may have that relate to the position applied for
Please list any professional licenses, designations, certifications, etc. that may relate to the position applied for. Include date granted, name of organization, and any other relevant information.

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Reference 2

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Applicant Certification Agreement


I voluntarily give Columbus Community Hospital, Inc. the right to make a thorough investigation of information given by me on this application form. I understand that information pertaining to past employment may include but is not limited to performance evaluations and reports, job descriptions, disciplinary reports, letters of reprimand and opinions regarding my suitability for employment possessed by it.

I voluntarily and knowingly fully release and discharge, absolve, indemnify and hold harmless such former employer, person, firm, corporation, school or government agency, its officers, employees and agents from any and all claims, liability, demands, causes of action, damages or costs except in the event of malicious and willful disclosure of derogatory facts concerning my employment made for the express purpose of preventing me from obtaining employment which the officer, employee or agent disclosing such facts known are untrue. 

I consent to take the physical examination upon offer of employment and any future relevant physical exams as required if employed. If employed, I will adhere to the rules and regulations of the hospital as stated in their policies and procedures.

I certify that the information supplied herein is true and complete, and I understand that any misrepresentation or omission of relevant information may disqualify me from employment now or may result in my discharge from the Hospital.

I understand that this application for employment shall be considered active for a period of time not to exceed six (6) months.

It is hereby understood and acknowledged that any employment relationship with this organization is of an "at will" nature which means that the employee may resign at any time and the employer may discharge employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless an authorized executive of this organization specifically acknowledges such change in writing.

Columbus Community Hospital fully supports the concepts of equal employment opportunity and will continue to do so. It is our policy to effect all personnel transactions, including, but not limited to recruitment and employment, promotion, demotion, transfer, compensation, and selection for training without discrimination and to ensure equal treatment of employees regardless of sex, sexual orientation, race, religion, color, national origin or ancestry, age, disability, marital status, source of income, arrest record or conviction record, membership in the national guard, state defense force or any reserve component of the military forces of the United States or State of Wisconsin, or any other unlawful basis.

Upon submitting your application, you understood and agree with the above terms and conditions.

Date: 07-17-2019
Need help?

If you having issues with the online application, please send your cover letter and resume to John Lange. Thank you for your patience as we transition to our new system!