710 N. Walnut Street, Medicine Lodge, KS 67104  |  Call Us: 620-886-3771 |  Clinic: 620-886-5949 | Clinic Hours

(Last) (First) (Middle) (Date)

(Street No.) (City) (State) (Zip)

(Home Phone) (Cell Phone) (Email)
Contact Info

Available Shift(s): DAY /EVENING /NIGHT /ANY Are you over 18 years of age? YES / NO
Available Start Date
Have you ever worked at MLMH&PC? If So, When?


Type Name and Location Graduate/Degree (Y/N) Major/Subjects of Study
High School YesNo
College / University YesNo
Specialized Training, Trade School, etc. YesNo
Other Education YesNo

Please list your areas of highest proficiency, special skills, or other items that may contribute to your abilities in performing the above-mentioned position.


Dates Employed Company Name Location Title / Role Wage/Salary


Name Business and Location Telephone Years Acquainted Relationship

Please answer the following:

Have you ever been convicted of a felony? Yes/No
Have you ever been convicted of any criminal offense relating to health care? Yes/No
Have you ever been listed by a federal agency as debarred, excluded, or otherwise ineligible for participation
in any federal health care program, either temporarily or permanently?

Medicine Lodge Memorial Hospital and Physicians Clinic is an equal opportunity employer regardless of race, color, religion, creed, sex, marital status, national origin, disability, age, veteran status, on-the-job injury, sexual orientation, political affiliation, or belief. Employment decisions are made without consideration of these or any other factors that are prohibited by law.

Employment is dependant upon satisfactorily passing a pre-employment physical, as well as a pre-employment drug screen. I hereby certify that the foregoing statements are true and correct to the best of my knowledge, and hereby grant Medicine Lodge Memorial Hospital and Physicians Clinic permission to verify such statements. I understand that any omissions, misrepresentations, or false statements on this application or in subsequent interviews may be considered as sufficient cause for rejection of this application, or for dismissal if such statements are discovered subsequent to my employment. I understand that a reference check will include, but not be limited to the above references and my previous employers, and I release all parties from all liability for any damage or claim that may result from furnishing Medicine Lodge Memorial Hospital and Physicians Clinic with any information they may have, personal or otherwise.

I hereby acknowledge that I have read and agree to the above statement.*