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Burgess Health Center
1600 Diamond Street|Onawa, IA 51040
712-423-2311
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Thank you for considering a career at Burgess Health Center. After you have completed your application, you will receive an email to confirm that we have received your information.

Personal Information
Name*
First Middle Last
Preferred Phone*
Email Address*
Address*
Street Address City State ZIP Code
What job are you applying for?*
- Advanced Practice Provider - Burgess Family Clinics
- BHIS Specialist - Mental Health Services
- Environmental Services Tech
- Med/Surg RN - Nights
- Medical Technologist
- Nurse Technician - Inpatient Services
- Paramedic
- Part-Time Med/Surg RN - Nights
- Physical Therapist
- RN - Emergency Services
- RN - PRN
- Therapist - Mental Health Services
You may select more than one.
General Information

Check the appropriate box next to each statement. Checking "yes" may not automatically disqualify you from employment. Non-disclosure of information may be considered falsification of records. Verification of the responses will be accomplished by conducting a sanction screening/criminal background check on all individuals to whom an offer of employment has been made prior to employment.
Are you over the age of 18?*
- Yes
- No
Can you, if hired, submit verification of your legal right to work in the United States?*
- Yes
- No
Have you ever had a professional license subject to suspension or revocation?*
- Yes
- No
Have you ever voluntarily relinquished your professional license?*
- Yes
- No
Have you ever been convicted of a Felony or Misdemeanor?*
- Yes
- No
If you answered yes to the question above, please explain here:
Are you charged with any unresolved criminal charges? (Are you charged with a crime that has not yet resulted in a plea of guilty, court trial, deferred adjudication, or dropping of the charge?)*
- Yes
- No
Have you ever been an employee or volunteer at Burgess Health Center?*
- Yes
- No
If yes, please list previous title(s) and any other names you used during your employment:
How did you hear about us?*
If you selected Employee Referral, please list the employee's name here:

These sections are required. Please upload a resume OR type all education, applicable license information, and previous work history (Extended Applicant Fields). Your application will not be submitted without either a resume or this section completed!
Choose One:*
Résumé/Cover Letter*
Max. file size: 40 MB.
Employment

Start with current or most recent position.
Number of past employers*
First Employer
Manager Name:*
Business Name:*
Your Position:*
Address*
Street Address City State ZIP Code
Start Date:*
MM slash DD slash YYYY
End Date:*
MM slash DD slash YYYY
Hourly Wage:
Description of Work Performed:*
Reason for Leaving:*
May we contact this employer?*
- Yes
- No
Second Employer
Manager Name:*
Business Name:*
Your Position:*
Address*
Street Address City State ZIP Code
Start Date:*
MM slash DD slash YYYY
End Date:*
MM slash DD slash YYYY
Hourly Wage:
Description of Work Performed:*
Reason for Leaving:*
May we contact this employer?*
- Yes
- No
Third Employer
Manager Name:*
Business Name:*
Your Position:*
Address*
Street Address City State ZIP Code
Start Date:*
MM slash DD slash YYYY
End Date:*
MM slash DD slash YYYY
Hourly Wage:
Description of Work Performed:*
Reason for Leaving:*
May we contact this employer?*
- Yes
- No
Fourth Employer
Manager Name:*
Business Name:*
Your Position:*
Address*
Street Address City State ZIP Code
Start Date:*
MM slash DD slash YYYY
End Date:*
MM slash DD slash YYYY
Hourly Wage:
Description of Work Performed:*
Reason for Leaving:*
May we contact this employer?*
- Yes
- No
Education

Start with current or most recent school.
Number of schools attended
School Name*
School Location*
City State
Years Attended*
Did you graduate?*
- Yes
- No
Second School
School Name*
School Location*
City State
Years Attended*
Did you graduate?*
- Yes
- No
Third School
School Name*
School Location*
City State
Years Attended*
Did you graduate?*
- Yes
- No
Fourth School
School Name*
School Location*
City State
Years Attended*
Did you graduate?*
- Yes
- No
Professional License Information

If applicable, list all professional license information. Please do not enter Driver's License information in this section.
Number of Licenses
Type of License or Certification
State Issued
State
License Number
Expiration Date
MM slash DD slash YYYY
Type of License or Certification
State Issued
State
License Number
Expiration Date
MM slash DD slash YYYY
Type of License or Certification
State Issued
State
License Number
Expiration Date
MM slash DD slash YYYY
Type of License or Certification
State Issued
State
License Number
Expiration Date
MM slash DD slash YYYY

References

List three references, other than relatives, who we can contact.
First Reference
Name*
Occupation*
How long have you known this reference?*
Phone Number*
Second Reference
Name*
Occupation*
How long have you known this reference?*
Phone Number*
Third Reference
Name*
Occupation*
How long have you known this reference?*
Phone Number*
Submit Application

By signing below, I certify that the answers and information set out above are true, accurate and complete to the best of my knowledge. I acknowledge that if any answer or information is not true, accurate or complete, I may not be hired, or if hired, I may be discharged. I authorize Burgess Health Center to investigate all statements contained in this application for employment and to investigate my character and qualifications. I authorize my prior employers, references, and others with information regarding my work or educational history or my character, to provide Burgess Health Center with all requested information and references, and to cooperate fully with the investigation of my character and qualifications.

I understand that this application is not a contract of employment. I also acknowledge that no oral representations have been made, and that no one within Burgess Health Center has the authority to make oral contracts of employment. If hired, my employment relationship with Burgess Health Center is terminable at-will, with or without cause, by either myself or Burgess Health Center. I also understand that my employment will be conditioned upon a favorable criminal and abuse registries background check and health evaluation including drug screening, which may include a medical examination by a physician selected by this employer, to which I hereby consent.

I agree to notify Burgess Health Center in writing within five (5) days of receiving any written or oral notice of any adverse action, including, without limitation, exclusion from participation in any federal or state health care or procurement programs, any filed and served malpractice suit or arbitration action; any adverse action by Licensing Board taken or pending; any adverse action which has resulted in the filing of a report with the Licensing Board; any revocation of DEA license; a conviction of any felony or a misdemeanor of moral turpitude; any action against any certification under the Medicare or Medicaid programs; or any cancellation, non-renewal or material reduction in medical liability insurance policy coverage.

I understand and agree to all of the conditions and statements set forth above, and throughout this application.

Signature
My typed name below shall have the same force and effect as my written signature.*
First Last
Signature Date*
MM slash DD slash YYYY
We require adherence to all federal, state, and local regulations. If you should have concerns, you should discuss them with your manager, Human Resources, or Compliance.

As a condition of employment, Burgess Health Center requires employees hired after February 29, 2008 to participate in direct deposit of the employees’ wages into a financial institution of the employee’s choice.
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1600 Diamond Street | Onawa, IA 51040

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