Employment Application

Home | About Us | Employment | Volunteer

Thank you for your interest in Story Medical. Story Medical prides itself on every employee being part of our story. The S.T.O.R.Y. values are of utmost importance to Story Medical and all employees are expected to adhere to these values at all times. Please take a moment to review these values to ensure your commitment before applying for employment with Story Medical.

Service: We value the positive encounters that come from delivering exceptional, quality care.

Our story is the healing environment and memorable experience we create for our patients, residents, families, visitors and our community.

Teamwork: We value results produced when all employees work together for the greater good.

Our story is the success that comes with the commitment, cooperation and fiscal responsibility of all employees.

Openness: We value the open and trustworthy environment developed through effective communication.

Our story is the goodwill created by open communication, both internally and externally.

Relationships: We value the benefits of being engaged in healthy personal and professional relationships.

Our story is the family atmosphere and work-life balance developed through relationship building.

Your Story: We value the insight we get from identifying every person’s personal story.

Our story is the story of every patient, resident, family member, visitor, employee and community member.

If you find that you would rather email your application to the Human Resources Department rather than completing the online application, please feel free to do so. Your resume can be submitted to ksiebrecht@storymedical.org.

Personal Information

PLEASE READ CAREFULLY: Story Country Medical Center is committed to the policy that all persons have equal access to its employment, programs and facilities without regard to race, color, religion, sex, national origin, age or disability. It is the applicant's responsibility to request any special arrangements needed to facilitate the application process.

First Name:
Last Name:
Middle Initial:
Mailing Address Line 1:
Mailing Address Line 2:
City:
State:
Zip Code:
Email Address:
Phone Number:
Mobile Number:
Job Desired:: CNA *Updated*
Dietary Aide/Cook
Housekeeper
MT/MLT
Registration Clerk
RN - Outpatient Clinic & Surgical Services
RN/LPN - Med Surg
RN/LPN - PRN
Unit Secretary
Other:
Position:: Full time
Part time
PRN
Temporary
Shift Preference:: Day
Evening
Night
Open
Have you ever worked for Story County Medical Center?: YesNo
Are you related by blood, marriage or adoption to any current employee at Story County Medical Center?: YesNo
Do you have a record of founded child or dependent adult abuse or have you ever been convicted of crime other than a simple misdemeanor offense relating to motor vehicles and laws of the road under chapter 321 or equivalent provisions in this state or any other state?: YesNo

If you drive for Story Medical you are required to have the appropriate current and unrestricted license. You will be required to furnish proof of your driving record as part of your application and may be required to release your driving record annually thereafter.

Education

High School

Name:
Location:
Courses of Study:
Diploma/Degree:

College/University

Name:
Location:
Courses of Study:
Diploma/Degree:

2^nd College/University

Name:
Location:
Courses of Study:
Diploma/Degree:

Military Training

Name:
Location:
Courses of Study:
Diploma/Degree:
Date of Discharge:

If licensed, registered, or certified, please provide the following information.

License/Number:
Date of Licensure:
State:
Your Field:
Expiration Date:

Employment

Failure to provide accurate and complete information may result in any offer of employment from Story Country Medical Center being withdrawn or the termination of your employment if the information is discovered to be inaccurate and/or incomplete after you have become an employee. Do not omit any prior employment within the past 10 years. Additional sheets for you to complete employment history will be provided upon request. Applicants with more than four previous employers in the last 10 years must bring a copy of these employers with them if selected for an interview.

From:
To:
Shift:: Full time Part time
Employer:
Address:
City:
State:
Zip Code:
Phone Number:
Title:
Specific Responsibilities:
Reason For Leaving:
Starting Salary:
Last Salary:
Supervisor:
May we contact this employer?: Yes No

References

Story Medical advises that you provide three business related references. These references can include, but are not limited to, current or previous supervisors, coworkers, academic advisors, professors, etc.

* at least 3 required

First Name:
Last Name:
Email Address:
Phone Number:

First Name:
Last Name:
Email Address:
Phone Number:

First Name:
Last Name:
Email Address:
Phone Number:

Finalize

I certify that the information contained in this application is correct and I understand and agree that the falsification, misrepresentation, or omission of any information in this application are grounds for refusal to hire or if I have been hired, grounds for termination. I authorize investigations including criminal, adult abuse and excluded provider background checks as necessary for employment. I understand and agree that if, in the judgment of Story County Medical Center, the results of the investigations are not satisfactory, any offer of employment made by Story County Medical Center may be withdrawn or my employment with Story County Medical Center may be terminated. I authorize the references listed in this application, including personal and employment references and all prior employers, to provide you with all information pertinent to this application. I release all parties from liability for any damages, which may result from the release of any information as a part of the employment verification process. All successful applicants must pass a physical exam prior to beginning employment at Story County Medical Center. I understand that an offer of employment is contingent upon my passing Story County Medical Center’s medical examination before starting work. If the examination discloses conditions that prevent me from safely and successfully performing the essential functions of the job, Story County Medical Center shall attempt to make accommodations that will enable me to work. If no reasonable accommodations can be found, or if such accommodations impose undue hardship on Story County Medical Center, the offer of employment will be withdrawn. I further acknowledge that I understand that Story County Medical Center has a policy of employment at will and if I am hired by Story County Medical Center my employment may be terminated either by myself or by Story County Medical Center at any time. I understand that employment is contingent upon successful completion of a job-required licensure, certification, or registration exam, if applicable and not already completed. I acknowledge that I have been advised that this application will remain active for six months from this date.

Digital Signature:: By signing this box, I understand that I am providing a digital signature verifying any and all information provided within this application.
To better focus our employee recruitment efforts, please tell us where you heard about the position you are applying for:: Career Builder
Newspaper advertisement
Story Medical website
Other website
Employment Agency
Current Employee
Recruitment/Job fair at
Other