Black Hills Surgical Hospital-

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Personal Information

* First name
* Last name
* Email
Address
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* Phone number

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Other Information

* Are you at least 18 years of age? Yes No

* Have you ever been employed here before? * Do you smoke, vape or otherwise use tobacco products? * When are you available to work? Days; Mornings; Afternoons; Evenings; Nights; Weekends; Holidays * Have you been convicted of a criminal offense related to health care or have you been debarred, excluded, or otherwise deterimined inelgible for participation in governmental healthcare programs.

If we contact you for a phone screen, when should we call? (pick as many slots as you wish) 8am to 11am 11am to 3pm 3pm to 6pm 6pm to 8pm Any of these times