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:
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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:
References:
Name
Occupation
Organization
Telephone
Address
May we contact your current employer as a reference?
Yes
No
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.