EMPLOYMENT APPLICATION Position: First Name: Home Phone: Business Phone: Street Address: City: State/ZIP: E.Mail Address: Sex: Male Female Ethnicity: White Black Hispanic Asian Pacific Islander Alaskan Native As Defined By The Vietnam Era Veteran Assistance Act of 1947, Are You In The Protected Group: Yes No Are You a U.S. Citizen: Yes No If not, do you have a legal right to work in the U.S.: Yes No Shift Desired: Full Time Day Shift As Needed Part Time Evening Shift Temporary Night Shift Summer Any Minimum Salary Desired: Date Available: Referred By: Employee Internet Newspaper Physician School Recruiting Fair Walk In Radio / TV Other If Other, Specify: Have You Ever Been Employed By A Sanford Facility: Yes No If Yes Where: Are You 18 Years or Older: Yes No If No What Is Your Age: Have You Attended School or Been Employed Under Another Name: Yes No If Yes, What Name: EDUCATION AND TRAINING High School: Date Graduated: College: Degree: Date Graduated: Technical School: Degree: Date Graduated: List Any Military Experience Which May Be Related To The Job For Which You Are Applying: EMPLOYMENT HISTORY Company Name: Company City & State: Company Phone: Supervisor Name: Job Title & Description: Hourly Rate / Salary: Dates of Employment: Company Name: Company City & State: Company Phone: Supervisor Name: Job Title & Description: Hourly Rate / Salary: Dates of Employment: Company Name: Company City & State: Company Phone: Supervisor Name: Job Title & Description: Hourly Rate / Salary: Dates of Employment: Company Name: Company City & State: Company Phone: Supervisor Name: Job Title & Description: Hourly Rate / Salary: Dates of Employment: REFERENCES Name: Present Title: Phone: Company Name & Address: Name: Present Title: Phone: Company Name & Address: Name: Present Title: Phone: Company Name & Address: Name: Present Title: Phone: Company Name & Address: SPECIAL SKILLS AND QUALIFICATIONS QUESTIONNAIRE Why are you interested in working with Sanford Hospitals and Health System? Where else have you applied? What position? What has been your most significant achievement? What has been your most significant failure? What did you do about it? Explain to us why we should hire you: APPLICANT ACKNOWLEDGEMENT AND AUTHORIZATION I hereby certify that all of the information provided by me in this application (or any other accompanying or required documents) is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts in said documents will be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery. I understand that submission of an application does not guarantee employment. I further understand that, should an offer of employment be extended by Sanford that such employment with Sanford is at will, for no specified duration and may be terminated by either Sanford or myself at any time, with or without cause or notice. I understand that none of the documents, policies, procedures, actions, statements of Sanford or its representatives used during the employment process is deemed a contract of employment real or implied. In consideration for employment with Sanford, if employed, I agree to conform to the rules, regulations, policies and procedures of Sanford at all times and understand that such obedience is a condition of employment. I understand that if offered a position with Sanford, I will be required to submit to a pre-employment health assessment, drug screening and background check as a condition of employment. I understand that unsatisfactory results from, refusal to cooperate with, or any attempt to affect the results of these pre-employments tests and checks will result in withdrawal of any employment offer or termination of employment if already employed. I herby authorize any and all schools, former employers, references, courts and any others who have information about me to provide such information to Sanford and/or any of its representatives, agents or vendors and I release all parties involved from any and all liability for any and all damage that may result from providing such information. Sanford is an Equal Opportunity Employer and expressly prohibits any form of unlawful employee harassment based on race, color, religion, gender, sexual orientation, national origin, age, disability, or veteran status. If you have any questions or need further assistance, please contact Sanford Human Resources at 605.842.7100. By clicking on the SUBMIT icon below, I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ABOVE STATEMENTS.