in Job Application | George Regional Health Systems

Job Application

 

Tell us about yourself

 

Please complete the application below. * denotes a required field.

Last Name: *
 
First Name: *
 
Middle Name:
Maiden Name:


Phone:
Email Address:


Present Address: *
 
City: *
 
State: *
 
Zip Code: *
 

Previous Address:

City:
State:
Zip Code:


Social Security Number: *
 

Are you 18 years old or older? *
 

Name of your Physician: *
 
Can you perform the job-related functions of the job you are applying for with or without reasonable accomodation? *
 
Please explain your need for accomodations:



General Application

 

You are completing a general application for employment with George Regional Health System. This application will be kept on file and reviewed if a job for which you are qualified becomes available. We will not contact you about this application unless we find a specific need to do so.

Tell us what you are looking for

 
Position applying for: *
 

Clinical Area Preferences:

1.

2.

3.


Desired Earnings: *
   

Can you work weekends? *
 

Shift Type:

Shift Preference:

What hours do you prefer?

Date you may begin work:

By whom were you referred?

If currently employed, why do you wish to change positions?


What are your long term occupational goals?


Military Service Information

 
Have you ever served in a miltary branch in the United States? *
 
Dates of Duty:

From:

To:

Rank at Discharge:

What were your duties in the service (include special training or skills and duty stations)?

Tell us about your education

 
Years of school completed: *
 
Years of college completed: *
 
Business or Trade School: *
 
High School Information
High School Name: *
 
Address:

City:
State:
Zip Code:

Degree Received? *
 
Graduation Year:

College Information
College Name:

Address:

City:
State:
Zip Code:

Major:

Minor:

Degree Received?
Graduation Year:

Graduate School Information
Graduate School Name:

Address:

City:
State:
Zip Code:

Major:

Minor:

Degree Received?
Graduation Year:

Business or Trade School Information
Business or Trade School Name:

Address:

City:
State:
Zip Code:

Major:

Minor:

Degree Received?
Graduation Year:

Other School Information
Other School Name:

Address:

City:
State:
Zip Code:

Major:

Minor:

Degree Received?
Graduation Year:

 

Extracurricular activities in school or college and offices held:

Tell us about your medical license

 
Are you applying for a job that requires a medical license?
Yes No

License Number:

State of Registration:

License Expiration Date:

Tell us about your clerical skills

 
Typing:

Machines or equipment you have skills to use:

Tell us about your previous employment

 
Most Recent Job Information
Company Name:

Supervisor Name:

Address:

City:
State:
Zip Code:

Telephone:

Date From:
Date To:

Wages:

Your Position:

Your Job Duties:



Reason for Leaving (if discharged, please include circumstances):



Job 2 Information
Company Name:

Supervisor Name:

Address:

City:
State:
Zip Code:

Telephone:

Date From:
Date To:

Wages:

Your Position:

Your Job Duties:



Reason for Leaving (if discharged, please include circumstances):



Job 3 Information
Company Name:

Supervisor Name:

Address:

City:
State:
Zip Code:

Telephone:

Date From:
Date To:

Wages:

Your Position:

Your Job Duties:



Reason for Leaving (if discharged, please include circumstances):



Job 4 Information
Company Name:

Supervisor Name:

Address:

City:
State:
Zip Code:

Telephone:

Date From:
Date To:

Wages:

Your Position:

Your Job Duties:



Reason for Leaving (if discharged, please include 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 Regional Health System is requesting you furnish information about prior convictions with the past ten years in the area or 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? *
 
Please specify and explain the conviction. Provide date of conviction and details of each conviction (nature of crime will be consdered in relation to position for which you are applying):



 

All Applicants
Have you ever used illegal drugs? *
 
Have you been convicted of a criminal violation other than a minor traffic offense? *
 
Please list the violations, the date of the conviction, sentence or 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.

Applicant Agreement

VERY IMPORTANT - PLEASE READ CAREFULLY
 

I understand and agree that George Regional Health System 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 compiled 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 Regional Health System may deem relevant to my application for employment. In exchange for consideration of my application, I also agree to release and hold harmless George Regional Health System 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 to 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 examination, test or investigation.

I also understand that, unless sometime in the future I enter into a specific, written employment contract with George Regional Health System, 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 its policies, rules and procedures at any time, and I agree that nothing in the company's policies, rules or procedures is to be constructed as a promise or guarantee of continued benefits or employment.

I understand that as a prospective employee at George Regional Health System that I must meet the demands of twnety-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.

Full Name (in lieu of signature): *