Skip to Content

PH: 563-652-2474
Contact Us
My Genesis

Main Navigation

Care & Treatment
Classes & Events
Careers
Patients & Visitors
Find a Doctor

Site Search

Call ahead with COVID-19 symptoms or exposure. | COVID-19 Vaccine Information & Sign-Up | Visitor Restrictions | Learn How Genesis Is Safe

Pay My Bill
Request an Appointment
View Health Records
Send a Cheer Card
Support Jackson County

expand/collapseI want to

You are here:

Home > Careers > Employment Application Form

Application Form for Jackson County Regional Health Center

APPLICATION FOR EMPLOYMENT
We are an Equal Opportunity Employer

* Denotes required fields

Today's Date

* Position(s) applied for:

PERSONAL

* First Name

M.I.

* Last Name

Maiden Name

* Social Security Number Example: 000-00-0000

* Address

* City

* State Example: NY

* ZIP Code Example: 12345

* Telephone Example: 123-123-1234 x123

Are you 18 years of age or older?

Yes
No

* Email

* Do you want to work

Full-time
PRN or temporary
Day
Evening
Night

If part-time, PRN or temporary, specify days and hours.

* Are you a U.S. Citizen or Resident Alien?

Yes
No

Have you worked for JCRHC or Genesis Health System? If yes, please list which company and dates of employment.

* Have you ever been convicted of a crime?

Yes
No

If yes, please explain.

If hired, when will you be available for work?

Best Time to contact You?

* How did you find out about this position?

Careers

Jackson County Regional Health Center Job Shadow Program

Careers
Billing
Support

Patient Right
Privacy Practices

Connect