For the Record
Last Name    
First Name    
Middle Name    
Maiden Name    
Your Email Address:    
Telephone    
Present Address Address: City State Zip
Previous Address Address: City State Zip
Are you 18 years of age or older?



   
Social Security Number    
Name of your physician    
Can you perform the job-related functions of the job you are applying for with or without reasonable accommodation? If you need reasonable accommodations, please explain those needs:
 


   
Your Career Preference
Position Applied for:    
Clinical Area Preferred: 1) 2) 3)
Desired Earnings: $    
Can you work weekends?



   
Shift Type




   
Shift Preference, if any: 1) 2) 3)
If part time, what hours would you be available to work?
Date you can begin work:


   
By whom were you referred?    
If now employed, why do you wish to change your position?
     
Military Service Record
Have you ever served in the military service of the U.S.?



   
Date of duty: From: To Rank at Discharge:
What were your duties in the service (include special training or skills and duty stations)?


     
Education
Year of school completed:


   
Years of College completed:
Business or other:
   

High School:

 

Name & Address
of School

 Major & Minor Degree Received Year
High School
College
Graduate School
Business or Trade School
Other
Extracurricular activities in school or college and office held:
License Registration No: Clerical Skills  
State you were licensed in: Typing
License expiration date: Shorthand

Long range occupational goals:

 WPM
Machines or equipment you have skills to use:
     

 

Employment History

List your last four jobs beginning with your last job first.

Job 1
Company Name Supervisor Name:
Address Your Position:
City and State Your Job Duties:
Telephone Dates: From to
Reason for leaving: Wage:
If discharged or asked to resign, please explain circumstances:
Job 2
Company Name Supervisor Name:
Address Your Position:
City and State Your Job Duties:
Telephone Dates: From to
Reason for leaving: Wage:
If discharged or asked to resign, please explain circumstances:
Job 3
Company Name Supervisor Name:
Address Your Position:
City and State Your Job Duties:
Telephone Dates: From to
Reason for leaving: Wage:
If discharged or asked to resign, please explain circumstances:
Job 4
Company Name Supervisor Name:
Address Your Position:
City and State Your Job Duties:
Telephone Dates: From to
Reason for leaving: Wage:
If discharged or asked to resign, please explain circumstances:
Comments regarding lapses between employers, if applicable:
Make any comments you feel we should know when we contact your previous employers:
   
     

 

Your Legal Responsibility
Those applying for Licensed Practical Nurse, Nurse Technicians, Operating Room Technician, Nurse Anesthetist, Pharmacist, Pharmacy Technician, Radiologic Technologist, Registered Nurse and Unit Clerk, please complete the following section. George County Hospital is Requesting you furnish information about prior convictions within the past ten years in the area of narcotic drugs or controlled substances.
       
Have you been convicted of possession or sale of any narcotic drug or controlled substance within the past ten(10) years?



If yes, please specify and explain giving date and details of each conviction (nature of crime will be considered in relation to position for which you are applying).
       
To All Applicants
Have you ever used illegal drugs?
Have you ever been convicted of a criminal violation other than a minor traffic offense?
If yes, please list the violations, the date of the conviction, sentence of fine imposed and circumstances surrounding the violation:

(A conviction record will not necessarily be a bar to employment. Factors such as age and time of offense, seriousness and nature of the violation, and rehabilitation will be taken into account.)
     
       
Agreement By Applicant

Very Important - Please Read Carefully

I understand and agree that George County Hospital may conduct or authorize another to conduct an investigation into my financial or credit history, workers' compensation history, personal background or mode of living. Should such an investigation be undertaken, I am entitled, upon written request, to receive a copy of any investigative report complied as a result thereof. I certify that all statements I have made on this application are true and correct, and I understand that any false statements may result in denial of employment or termination of my employment if I have already been hired. I authorize the Company to conduct investigations it deems appropriate to verify the statements I have made in this application and I hereby request my former employers and their representatives to release all information in their possession which George County Hospital may deem relevant to my application for employment. In exchange for consideration of my application, I also agree to release and hold harmless George County Hospital and any former employer or employer representative from any liability which they may incur in connection with the release of such information.

I agree to submit a polygraph (lie detector) examination and also agree to submit to further examinations and testing as the Company may require. I agree that the Company may disclose to its employees, managers, agents and others, as it reasonably deems necessary, the information gathered during any such examinatio, test or investigation.

I also understand that, unless sometime in the future I enter into a specific, written employment contract with George County Hospital, the employment relationship between the Hospital and me is freely terminable at the will of either party. I agree that, this at-will relationship cannot be altered in any way except by express written notice by the Hospital Administrator. I understand that the company is free to modify or revoke it's policies, rules and procedures at any time, and I agree that nothing in the company's policies, rules or procedures is to be construed as a promise or guarantee of continued benefits or employment.

I understand that as a prospective employee at George County Hospital that I must meet the demands of twenty-four (24) hour-a-day patient care and understand that overtime work will sometimes be necessary, therefore, I agree to undertake such overtime work.

I understand that this application will be given active consideration for only 60 calendar days and that I may thereafter apply again if I wish to receive continued consideration. I have read and I understand and agree to the foregoing.
Date Signature of Applicant: