Application for Employment

Thank you for your interest in employment at Story Medical! Please complete the application below as completely as possible to be considered for the position you are interested in. We ask that you also review the statements to the right prior to submitting your application.

Last Name

First Name

Middle Initial

Email Address

Phone Number

Alternate Phone Number

Current Address

City

State

ZIP Code

What Position Are You Applying For?

Wage Desired

Negotiable?

Seeking Work Status (select one)

Employment History (Two Most Recent Positions, If Applicable)

Business or Employer's Name

Address

City

State

ZIP Code

Position

Dates Employed (From - To)

Supervisor's Name

Reason for Leaving

Briefly Describe the Work You Performed

Business or Employer's Name

Address

City

State

ZIP Code

Position

Dates Employed (From-To)

Supervisor's Name

Reason for Leaving

Briefly Describe Your Duties

High School

High School Name

City

State

ZIP Code

Have You Earned a Degree or Diploma?

Are You Currently Taking Classes?

Post Secondary (College or University)

College or University Name

City

State

ZIP Code

Major/Area of Study

Did You Earn a Degree or Diploma?

Are You Currently Taking Classes?

Technical/Vocational School

School Name

City

State

ZIP Code

Major/Area of Study

Did You Earn a Degree or Diploma?

Are You Currently Taking Classes?

Training Programs or Additional Education

Program Name

City

State

ZIP Code

Major/Area of Study

Did You Earn a Degree or Diploma?

Are You Currently Taking Classes?

Professional Licenses, Registrations and/or Certifications

Type

Number

Issuing State

Date Issued

Date Expires

References

Please list three references below we can contact to verify your qualifications for this position.

Reference 1 Name

Title

Organization

Phone

Email Address

Length of Time Known

Reference 2 Name

Title

Organization

Phone

Email Address

Length of Time Known

Reference 3 Name

Title

Organization

Phone

Email Address

Length of Time Known

Additional Information

Have you ever been employed by Story County Medical Center?

If yes, please provide dates employed.

Are you eligible and able to provide proof of eligibility to be legally employed in the United States?

Are you able to perform the duties of the position for which you have applied, with or without reasonable accommodation?

How did you hear about this position?

Story County Medical Center employee (if yes, please enter name of employee below)

Story County Medical Center website

Job board (if yes, please list which board or boards below)

Social media (if yes, please list which channel or channels below)

Iowa Workforce Development

Job Fair

Postcard

Other (please provide specific information below)

Story County Medical Center Employee Name

Job Board(s)

Social Media Channel(s)

Other

Please read the statement below and click the box to acknowledge. To review the policy, scroll to the top.

I acknowledge and understand that Story County Medical Center is a tobacco-free worksite and that I will not be permitted to use tobacco or tobacco-like products as defined in the Story County Medical Center's Tobacco-Free Worksite Policy.

Please check this box to certify all answers provided here are true and complete.

Yes. I certify all answers are true and complete.

Typing your name in the box below serves as your legal signature in submitting this application.

You May Upload a Cover Letter if Desired

You May Upload a Resume if Desired

Contact Us

Story County Medical Center
640 South 19th Street
Nevada, Iowa 50201
Phone: (515) 382-2111
Fax: (515) 382-7760

Please Review Prior to Submitting Your Application

Before submitting your application, you must acknowledge you understand that Story County Medical Center is a tobacco-free worksite and that I will not be permitted to use tobacco or tobacco-like products as defined in the Story County Medical Center’s Tobacco-Free Worksite Policy. CLICK HERE to read the policy.

Please Review Prior to Submitting Your Application

Toward the end of this application, you will be asked to certify that all the answers given in this application are true and complete. In providing certification, you authorize investigation of all statements contained in this application and understand that any omission or false or misleading information will be sufficient cause for disqualification from consideration for employment or for dismissal. You release this organization and all providers of information from any liability as a result of furnishing and receiving this information. You understand that any offers of employment are contingent upon successful completion of the post offer exam and backgrounds checks. You understand employment at this organization is "at-will" which means employment may be terminated by the employee or by this organization at any time with or without cause.