Application for Employment
It is the policy of Keefe Memorial Health Service District to provide equal opportunity to persons regardless of race, religion, age, gender, disability or any other classification in accordance with federal, state and local statutes, regulations and ordinances.

Human Resources Department
602 North 6th Street West
Cheyenne Wells, Colorado 80810
www.keefememorial.com

Contact Information
First Name
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Middle Initial
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Last Name
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Any other names used (including maiden name)
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Current Street Address
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City
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State
Zip Code
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Phone Number
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Email Address
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Date of Birth
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Are you at least 18 years old?
Gender
Social Security Number
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Driver's License Number
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State of Issue
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