Employment Application

Application for Employment

  1. Van Buren County Hospital does not accept unsolicited applications and applications are only valid for 60 days.

  2. Personal Information

  3. NOTE: A conviction record will not necessarily disqualify an applicant from employment. The circumstances of the conviction will be considered in relation to the nature and duties of the job applied for.

  4. Prior Employment

    List your last three jobs, beginning with the most recent (you may omit dates for jobs held for more than five years ago)

    Employer 1

  5. Add Employer

    Education and Training

  6. Please list technical or trade school, college and post-graduate education, if any:


  7. Add School/College

    Other Skills

  8. Veteran Status

    Are you a veteran of the armed forces of the United States?

    Yes, enter Veteran information


    Please list three personal references, other than prior employers or relatives, whom we can contact.

    Reference 1

  9. Reference 2

  10. Reference 3

  11. Optional: Upload Resume

  12. Van Buren County Hospital

    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 Van Buren County Hospital 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 education history or my character, to provide Van Buren County Hospital with all requested information and references, and to cooperate fully with the investigation of my character and qualifications.

    I understand that Van Buren County Hospital does not accept unsolicited applications and that applications are only valid for 60 days.

    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 Van Buren County Hospital has the authority to make oral contracts of employment. If hired, my employment relationship with Van Buren County Hospital is terminable at-will, with or without cause, by either myself or Van Buren County Hospital.

    I also understand that any offer of employment will be conditioned upon my passing a pre-employment physical examination, which may include a drug and/or alcohol test and may include a medical examination by a physician selected by Van Buren County Hospital, to which I hereby consent.

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

    Your Signature

  13. Please type your full name to serve as an electronic signature.

  14. Applicant Information

    Van Buren County Hospital, is an Affirmative Action/Equal Opportunity Employer and does not discriminate on the basis of race, color, religion, sex, age, national origin, disability, veteran status, or any other classification protected by Federal, state, or local law.

    This information will be used strictly for statistical record-keeping purposes and will be kept confidential. Providing—or not providing—the gender/race/ethnic/veteran’s status information on this form will neither impact whether or not you are hired, nor will it affect your employment in any manner if you are hired. If you choose not to self-identify, you must select the declination box below to move forward with the application process. The person(s) making hiring and personnel decisions will not see this form.

    If you prefer not to self-identify, select "Prefer not to disclose" in each box below.

  15. Voluntary Self-Identification of Disability

    Form CC-305, OMB Control Number 1250-0005

    Why are you being asked to complete this form?

    We are a federal contractor or subcontractor. The law requires us to provide equal employment opportunity to qualified people with disabilities. We have a goal of having at least 7% of our workers as people with disabilities. The law says we must measure our progress towards this goal. To do this, we must ask applicants and employees if they have a disability or have ever had one. People can become disabled, so we need to ask this question at least every five years.

    Completing this form is voluntary, and we hope that you will choose to do so. Your answer is confidential. No one who makes hiring decisions will see it. Your decision to complete the form and your answer will not harm you in any way. If you want to learn more about the law or this form, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website.

    How do you know if you have a disability?

    A disability is a condition that substantially limits one or more of your “major life activities.” If you have or have ever had such a condition, you are a person with a disability. Disabilities include but are not limited to:

    View List of Disabilities

  16. PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

This content was printed from the Van Buren County Hospital website at vbch.org on May 21, 2024.

Our Mission

Dedicated to enhancing health and well-being through compassionate and personalized healthcare and services.


304 Franklin St. | Keosauqua, IA 52565

To report a Compliance or Privacy concern or incident, please contact compliance@vbch.org.
You can also contact our Compliance Officer; Lynn Kracht at 319-293-8716 or Lynn.Kracht@vbch.org.

Need an Estimate? | Hospital Price Transparency

If you speak another language, assistance services, free of charge, are available to you. Call 1-319-293-3171

Español   |   中文   |   Tiếng   |   Việt   |   한국어   |   Tagalog   |   русский   |   العربية   |   Français   |   Deutsch   |   日本語   |   فارسی   |   हिन्दी   |   ગુજરાતી   |   አማርኛ   |   ພາສາລາວ