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Employment Application


Personal Information (must be filled completely)

* Are required fields
*First Name:
*Last Name:
Middle Initial/Maiden:
*Address
*City
*State
*Zip
*Telephone
Cell Phone
 
*Emergency Contact Name:
*Emergency Contact Number:
*Relationship:
  *Are you at least 18 years of age:
E-Mail Address
 

Employment Information

Position Applied For:
Date Available
*Type of Employment:



*Shift Available:



Are you eligible for employment
in this country?

Past Employment Information

Have you ever been employed by Jasper General Hospital?
What Name:
Date:
Department:

Have you ever been discharged or requested to resign from a job?
Have you ever been the subject of any adverse actions, by any duly authorized sanctioning or disciplinary agency for either conduct-based or performance-based activities?
Have you even been convicted of any criminal violation law or pending investigation for charges of violation of criminal law?

Education

High School School Name: Years Completed: Academic Major: Degree Received:
College School Name: Years Completed: Academic Major: Degree Received:
Trade/Buss./Tech. School Name: Years Completed: Academic Major: Degree Received:
Advanced Degree School Name: Years Completed: Academic Major: Degree Received:

Skills & Qualifications

Summarize special skills & qualifications Acquired from employment or other experiences that may
qualify you for work with our company, such as typing (WPM+, Computer, Knowledge, etc)

Employment History

Name of Employer #1
Employer Address
City
State
Zip
Date Started
Date Ended
Salary
Your Position
Duties
Name of Immediate Supervisor
Reason for Leaving

Name of Employer #2
Employer Address
City
State
Zip
Date Started
Date Ended
Salary
Your Position
Duties
Name of Immediate Supervisor
Reason for Leaving
May we ask your present employer for a reference?

Stark Requirement

The stark regulation published in August 1995 requires hospitals and health care providers to submit to HCFA information concerning employee relationships with physicians utilizing the services of the reporting facility or making referrals to the reporting facility.
If you are related to a physician that refers to this facility or on the medical staff of this facility, please complete the following questions. If you are not related to referring physician, please answer only question one.

    1. Are you presently or have you ever ben related to a physician on staff at this facility or a physician that refers to our facility?
    2. If you where related to a physician by marriage or any other relationship and that relationship no longer exists, give the dates of this relationship. Start date and end date .
    3. If you are related to a physician that is on staff or refers patients to the facility, give the following information:


       
Name of related physician
Date of hire
Relationship to physician
 
Your position or responsibility

References (Please do not list relatives)

Name
Address
City
State
Phone#
Name
Address
City
State
Phone#
Name
Address
City
State
Phone#

I certify that the information on this application is true and complete to the best of my knowledge. I understand that I may be refused employment or discharged at any time after employment if any information I have given is found to be false or substantially misleading. I grant permission to the hospital or its agents to investigate and verify all information and preferences given within. I release your organization and all former employers, schools, references given within. I release your organization and all former employers, schools, references and law enforcement agencies from any liability whatsoever for providing the information for investigation. If employed, I agree as a condition of employment to acquaint myself with and to abide by all rules and regulations, and policies established or amended by the hospital, including, but not limited to, authorizing the hospital to conduct a personal credit check as part of an internal theft or embezzlement investigations. I understand that my employment is at will and is for no definite period of time and may be terminated at any time. I am also willing to have a drug screening at the company expense for the presence of the drugs realizing my employment is contingent upon completion of a favorable pre-placement drug screening.

Jasper General Hospital/Jasper County Nursing Home/ Pro-Care Home Health/Summerland Manor offers equal opportunity for employment of all applicants without regard to race, color , religion, sex, national origin, disability, age, or military status.