A child being held by grandpa and kissed by grandma

Join Our Team

Interested in joining our team? Please submit the form below, and a Human Resource representative will contact you shortly.

Required fields are marked with *

Personal Information

Position applying for *
Interested in *
Are you 18 years old or older? *
Have you been employed by this facility? *
Relatives employed here? *
Are you legally authorized to work in the US? *
Have you ever been convicted of, or plead guilty to a crime (excluding misdemeanor or traffic violation)? *
Have you ever been involved in the substantiated abuse or neglect of children or adults under the laws of this stated or any other stated in the US? *
Have you ever been sanctioned, cited, reported or excluded from participation in Medicare, Medicaid, or any other healthcare related law of regulations? *
Can you do the position you’re applying for with reasonable accommodations? *


High School


Additional College

Additional Training

Professional Licenses/Certifications

Are you currently eligible for:
Has your licensure, certification or registration ever been revoked, suspended, or restricted in any way?



Give a complete record of all employment and reasons for periods unemployed during the past ten years. Start with most recent employment.

   Business or Employer's Name
May we contact for a reference?

Employment History

Can we run a detailed employment check, including but not limited to a check, with previous employers? *
Did you serve in the U.S. Military? *
Have you volunteered your time or services? *


Please list the names of three persons - who are NOT relatives or friends - we may contact to verify your qualifications for the position.

Reference #1

Reference #2

Reference #3


Please upload one additional document you would like included with your application. (e.g. Resume, Cover Letter, Reference, Licensure, etc.)

Signature for Authorization

In consideration of my employment, I agree to conform to the rules and regulations of this facility. I understand that my employment can be terminated at any time and for any reason, at the option of either the facility or myself. I understand that no one has any authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing, except for a written employment agreement signed by an administrative representative of this facility.
I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete. I understand that any false or misleading representations or omissions may disqualify me from further consideration for employment may result in discharge even if discovered at a later date.
I hereby authorize persons, schools, my current employer (if applicable) and previous employers and organizations named in this application (and accompanying documentation, if any) to provide this facility and all affiliates with any relevant information regarding an employment decision, and I release all such persons from any liability regarding the provision or use of such information.

Background Check Authorization

I hereby authorize Blessing Health Keokuk and/or its agents to make an independent investigation of my background, references, past employment, education, criminal or police records, including those maintained by both public and private organizations, and all public records for the purpose of confirming the information contained on my application and/or obtaining other information which may be material to my qualifications for employment now and, if applicable, during the tenure of my employment with Blessing Health Keokuk.
I release Blessing Health Keokuk and/or its agent and any person or entity, which provides information pursuant to this authorization, from any and all liabilities, claims or lawsuits in regarding to the information obtained from any and all of the above referenced sources used.
The following is my true and complete legal name and all information contained herein is true and correct to the best of my knowledge.

Optional: Applicant Data Record

Qualified applicants are considered for all positions, and employees are treated during employment without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical condition or handicap. As employers/government contractors, we comply with government regulations and affirmative action responsibilities. Solely, to help us comply with government record keeping, reporting and other legal requirements, please fill out the Data Record. This Data is for periodic government reporting and will be kept in a confidential file separate from the Application for employment.

Affirmative Action Survey

Government agencies require periodic reports on the gender, ethnicity handicapped and veteran status of applicants. This data is for analysis and affirmative action only. Submission of this information about handicap is voluntary.