JASPER COUNTY HOSPITAL
Application for Employment
           
Position Desired:         Date:
Please read carefully, and answer all questions. Federal and State laws prohibit discrimination in employment because of race, color, creed, age, sex, marital status, national origin, physical or mental impairment, or medical condition.
First Name: Last Name: Middle Initial:
Social Security Number: Email Address:    
Street: Apt Number:    
City:      State:      Zip Code:     
Home Telephone: Cellular Telephone: Other Telephone:
Sex:
Male
Female
Are you under 18 years of age?
Yes
No 
If yes, date of birth:
Have you served in the United States Military?
Yes
No 
Are you a U.S. Citizen or alien legally authorized to work in the U.S.?
Yes
No 
Please mark all that apply:
Have you ever been employed by Jasper County
Hospital previously?
Yes
No 
If yes, under a previous name,
please state name:
Will you accept:
Part Time work 
Full  Time work 
Temporary work
Shift hours you can work:
Days     
Evenings
Nights   
Are you available?
Weekends
Holidays   
Are you willing to take a
drug test upon employment?
Yes
No 
Please complete the following:
Languages other than English that you can read, write or speak:

List software that you are skilled in:

Can you safely perform the essential functions of the position for which you are applying?
Yes
No 
If no, please explain:  
Have you at any time in the past, or in the present, been charged, convicted, fined, penalized, or otherwise told you cannot work for a federally funded health care program because you violated federal or state laws pertaining to health care reimbursement (i.e. Medicare, Medicaid, etc.)?
Have you ever been convicted of a crime? If yes, explain and include dates:
Do you have any pending criminal actions that are not resolved?
Yes
No 
Other job related information, skills, comments, or interests you feel may be helpful to us in considering your application?
Education:
Institution Major Dates Attended
(from year-thru year)
Degree Awarded Year
Work Experience:
From:
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To:
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Company Name:  Phone: 
Address:  Position: 
Supervisor:  Salary: 
From:
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To:
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Company Name:  Phone: 
Address:  Position: 
Supervisor:  Salary: 
From:
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To:
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Company Name:  Phone: 
Address:  Position: 
Supervisor:  Salary: 
From:
/ /
To:
/ /
Company Name:  Phone: 
Address:  Position: 
Supervisor:  Salary: 
From:
/ /
To:
/ /
Company Name:  Phone: 
Address:  Position: 
Supervisor:  Salary: 
From:
/ /
To:
/ /
Company Name:  Phone: 
Address:  Position: 
Supervisor:  Salary: 
References:
Name Occupation Organization Telephone Address
May we contact your current employer as a reference?
Is your application ready for submission? Yes
By submitting this application I certify that the answers given by me to the foregoing questions and statements are true and correct without consequential omissions of any kind. I agree that my employer shall not be liable in any respect if my employment is terminated because of falsity of statements, answers, or omissions made by me in this questionnaire. I authorize employers, companies, schools or persons named above to give any information regarding my employment together with any information they may have regarding me whether or not it is in their records. I hereby release said employees, companies, schools, or persons from all liability for any damage, both legal and otherwise, for issuing this information. I also understand a conditional offer of employment may be based on results of later medical examination. In addition, if accepted for employment, I hereby agree to abide by the rules and policies of my employer. Further, I understand that any employment is not for a stated period of time and may be terminated with or without cause, with appropriate notification per hospital policy, at any time, at the option of either myself or my employer. In addition, should my employer be or become subject to the condition of the Drug-Free Workplace Act of 1988, I agree to abide by such established policies as relates thereto.