Applicants are considered without regard to race, color, religion, sex, national origin, age, disability, sexual orientation and gender identity or any other prohibited basis of discrimination, as provided under applicable state and federal law.

Name: Address:
City: State:
Zip: Phone:
Email Address: Social Security Number:
Date of application: Position Applied For:
Referral Source:  Advertisement Friend Employee Relative Walk-In Private Agency Other
Name of Source (if applicable):

Have you ever been employed here before? Yes No If yes, give date
Are you employed now?  Yes No May we contact your present employer?  Yes No
May we contact you at work?  Yes No If yes, work number
Best Time to Call:
On what date would you be available for work?  Expected salary: 
Are you available to work: Full-time Part-time Temporary
Will you work overtime if required  Yes No
List professional, trade, business or civic activities and offices held. (You may exclude those which indicate race, color, religion, sex, age, national origin, disability).


Type Name/Address Course of Study Circle last year completed Did you graduate? Diploma/Degree Comments
High School 1 2 3 4 Yes No
College 1 2 3 4 Yes No
College 1 2 3 4 Yes No
College 1 2 3 4 Yes No
Technical,Business or Professional 1 2 3 4 Yes No
Has your professional license ever been suspended, conditioned or revoked in any state? Yes No
If yes, explain
Please list all states where you have been licensed or certified

Professional Licenses/Certifications:
Type State Exp. Date Registration Number

Start with your present or last job and include employment for the last 10 years. Include military service assignments and volunteer activities. Exclude organization names which indicate, for example, race, color, religion, sex, age, disabilit y or national origin.

Employer name Address Phone Number
Job Title:
Dates Employed Immediate Supervisor Last Salary- Hourly, Monthly, or Yearly
Summarize the nature of the work performed:
Reason for leaving:
May we contact for reference? Yes No Later

Employer name Address Phone Number
Job Title:
Dates Employed Immediate Supervisor Last Salary- Hourly, Monthly, or Yearly
Summarize the nature of the work performed:
Reason for leaving:
May we contact for reference? Yes No Later


Note: Please only upload pdf, word doc, or image files.

List Names and telephone number of three business/work references who are not related to you and are not previous supervisors . If not applicable, list three school or personal references who are not related to you

Name Telephone Years Known

State any additional information you feel may be helpful to us in considering your application or comments.


I understand and agree that any misrepresentation by me in this application will be sufficient cause for rejection of this application and/or termination of employment if I am hereafter employed by the Company. Furthermore, if I am hired, I understand that I am free to resign at any time, and that the Company reserves the right to terminate my employment at any time, with or without cause, and without prior notice. I understand that no such employment relationship must be made in writing and signed by an authorized representative of the Company. I understand that if you make an offer of employment to me it may be a conditional offer of employment. I may be required to submit to a pre-employment medical exam, to provide information in response to your medical inquiries, the results of which might disqualify me from employment. If requested, I agree to furnish such information and to submit to such examinations. I understand that I may be requested to submit to a test to detect the current illegal use of drugs, and if the test results identify that I am a current illegal use of drugs I will not be eligible for employment by the Company. I further understand that I have the right to refuse to s ubmit to such tests of my own free will. I authorize the Company to make a thorough investigation of my past employment, education and job-related activities. To the extent permitted by law , I release the Company from any liability which might result from making such investigation and I also release from any liability all persons and entities supplying such inf ormation. I acknow ledge that the Company is an equal opportunity employer and that the Company does not discriminate in employment. I understand that no question on this application is used for the purpose of limited or excluding the Company's consideration of me for employment on a basis prohibited by federal, state or local law , nor is it used by the Company for the purpose of attempting to obtain information prohibited by federal, state or local law . I understand that the Company will consider this application to contain current information for a period of only sixty (60) days. At the expiration of sixty (60) days, if I have not heard from the Company and if I still desire to be considered for employment I understand that it will be necessary for me to complete new application.

Print Name: Signature:

Read what our patients say

Read more

Contact Us:

Mason City Surgery Center, 990 4th Street S.W., Mason City, Iowa 50401

Nondiscrimination Notice

"MCSC complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, or religion." Click here for a full copy of this notice.

Mason City Surgery Center is a multi-specialty ambulatory surgery center providing Otolaryngology (ENT), General surgery, Gastrointestinal (colonoscopy), Gynecology, Ophthalmology (including cataracts), Orthopaedics, Pain Management, Plastic & Reconstructive Surgery, Podiatry, and Urology, procedures. The center is located at 990 Fourth Street SW, Mason City, IA 50401. Call 641-494-2000 or 877-704-0038.