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Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to he application and/or interview process should notify a representative of the Human Resources Department.

Applying to Which Position?
(Browse Open Positions)
Name (Last, First Middle)
Address
City:
State and Zip
Home Phone
Cell Phone
Other Phone
Email
If you are under 18, and it is required, can you furnish a work permit?  Yes No.
If no, explain:
Have you been employed here before?  Yes No?
If so, when and in what capacity?
Are you legally eligible for employment in the United States?  Yes No.
Date available to work:
Have you ever been excluded from participating as a provider in Medicare/Medicaid or any Healthcare Program?
 Yes No.
Type of employment desired:  Full-Time Part-Time Temporary
Are you able to meet the attendance requirements for this position?  Yes No
Have you ever been convicted of a crime?  Yes No If yes, please explain:

EMPLOYMENT HISTORY

Provide the following information for your past three (3) employers, assignments or volunteer activities, starting with the most recent.
1.)
Date Started - Ended
-
Employer
Job Title
Address
Immediate Supervisor / Title
Telephone
Summarize the nature of work performed and job responsibilities
Reason for Leaving
Hourly salary (rate):
Start: $ Per:
Final $: Per:
2.)
Date Started - Ended
-
Employer
Job Title
Address
Immediate Supervisor / Title
Telephone
Summarize the nature of work performed and job responsibilities
Reason for Leaving
Hourly salary (rate):
Start: $ Per:
Final $: Per:
3.)
Date Started - Ended
-
Employer
Job Title
Address
Immediate Supervisor / Title
Telephone
Summarize the nature of work performed and job responsibilities
Reason for Leaving
Hourly salary (rate):
Start: $ Per:
Final $: Per:

SKILLS and QUALIFICATIONS

Summarize any training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying:

LICENSES or CERTIFICATIONS

Applicable only to medical personnel requiring state license
License or Certification Number
State Issued
Association
Date Issued

EDUCATIONAL BACKGROUND

1.)
High School
City State
Years Completed
-
Year Graduated
2.)
College/School Name
City State
Year Started - Completed
-
Course Work / Major
Degree

MILITARY

US Military Naval Service: Rank:
Present Membership
National Guard Services:
Type of Discharge:

REFERENCES

1.)
Name
Telephone
Relationship
2.)
Name
Telephone
Relationship
3.)
Name
Telephone
Relationship
4.)
Name
Telephone
Relationship
Upload Your Resume (.pdf, .doc or .docx)

I understand that if I am employed, an misrepresentation or material mission made by me on this application will be sufficient cause for cancellation of this application or immediate discharge from Candler County Hospital’s (CCH’s) services whenever it is discovered.

I give Candler County Hospital (CCH) the right to contact and obtain information from all references, employees, educational institutions and to otherwise verify the accuracy of the information contained in this application. I hereby release from liability CCH and its representatives for seeking, gathering and using such information and all other persons, corporations or organizations for furnishing such information.

This application is current for only six (6) months. At the conclusion of this period, if I have not heard from CCH and still wish to be considered for employment, it will be necessary to fill out a new application.

If I am hired, I understand that I am free to resign at any time with or without prior notice and CCH reserves the same right to terminate my employment at any time with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no representative of the employer, other than an authorized officer, has the authority to make any assurances to the contrary. Further I understand that any such assurance must be in writing and signed by an authorized officer.

I understand it is Candler County Hospital’s policy not to refuse to hire a qualified individual based upon that person’s need for a reasonable accommodation as required by the ADA.

I also understand that If hired, I will be required to provide proof of identity, legal work authorization, physical examination, drug screen, criminal background check and to serve the best of my ability and to abide by the policies established by the hospital authority and the administrator.
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