Name and Address of High School
Dates Attended
to
Graduate?
YesNo
Date

Name and Address of College
Course or Major
Dates Attended
to
Graduate?
YesNo
Degree or Diploma
DegreeDiploma

Name and Address of Other
Course or Major
Dates Attended
to
Graduate?
YesNo
Degree or Diploma
DegreeDiploma

Name and Address
Telephone Number
Email Address

Name and Address
Telephone Number
Email Address

Name and Address
Telephone Number
Email Address

Employer's Name
May We Contact?
YesNo
Dates of Employment:
to
Employer's Address
Telephone#
Supervisor's Name
Title
Duties
Reason for Leaving
Email address
Starting Salary
Ending Salary

Employer's Name
May We Contact?
YesNo
Dates of Employment:
to
Employer's Address
Telephone#
Supervisor's Name
Title
Duties
Reason for Leaving
Email address
Starting Salary
Ending Salary

Employer's Name
May We Contact?
YesNo
Dates of Employment:
to
Employer's Address
Telephone#
Supervisor's Name
Title
Duties
Reason for Leaving
Email address
Starting Salary
Ending Salary

List Number and Exiration Date of any Professional Occupational license
State
Driver's License #(Last four digits)
Are You Computer Literate? What Software?
Typing Speed?
Office Equipment?

Have you ever worked for Clinch Memorial Hospital before?
[checkboc previous_clinch_employment_yes_no exclusive "Yes" "No"]
If yes, give dates:
to

I hereby state that the information given by me in the application is complete and true in all respects. I understand that any
omission, misrepresentation, or falsification will preclude my application from further consideration. I further understand that if
employed, the subsequent disclosure of any omission, misrepresentation, or falsification of information may result in the
termination of my employment.

If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the
employer reserves the same right to terminate my employment at any time, with or without cause and 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 supervisor or representative of the employer is authorized to make
any assurances to the contrary and that no implied oral or written agreement contrary to the foregoing express language are
valid unless they are in writing and signed by the employer’s administrator.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United
States and that federal immigration laws require me to complete an I-9 Form in this regard.

I understand that reasonable safeguards will be taken to protect all personal information provided or obtained in conjunction
with this application for employment. My personal information may be shared with the employer’s affiliate(s) and third parties
engaged by the employer to perform services for the employer. Any personal information shared with an affiliate or third party is
to be used solely to perform the services requested by the employer.

I understand that Clinch Memorial Hospital reserves the right to require its applicants to submit to a drug test. I understand that
refusal to submit to a drug test or a positive test result may preclude my application from further consideration. I further
understand that Clinch Memorial Hospital reserves the right to require its employees to submit to blood tests or urinalysis for
alcohol or drug screens, or to allow inspection of bags (including purses or brief cases) or parcels brought into or taken out of
Clinch Memorial Hospital. I understand that, if employed, a positive test result or a refusal to submit to a urinalysis, blood test or
search, when requested to do so may result in termination of my employment.

Clinch Memorial Hospital does not tolerate unlawful discrimination in its employment practice. No question on this application is
used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex
(including pregnancy), race, color, religion, national origin, citizenship, age, disability, genetic information, or any other protected
status under applicable federal, state, or local law.

I hereby authorize Clinch Memorial Hospital to make all necessary and appropriate investigations to verify the information
contained herein including a report of prior convictions and authorize my former employers to release information pertaining to
my work record, my work habits, and my work performance while in their employ.

DO NOT SIGN UNTIL YOU HAVE READ THIS ABOVE CERTIFICATION OF APPLICANT.
I certify that I have read, fully understand and accept all terms of the foregoing Certification of Applicant.

Signature of Applicant
Date:

Clinch Memorial Hospital is an equal opportunity employer. As required by law, we must record certain information to
be made a part of our affirmative action program.

Applicants for employment are invited to participate in the affirmative action program by reporting their status as a
protected veteran or other minority. In extending this invitation, we advise you that: (a) workers (applicants) are under
no obligation to respond but may do so in the future if they choose; (b) responses will remain confidential within the
human resource department; and (c) responses will be used only for the necessary information to include in our
affirmative action program. We are a company that values diversity. We actively encourage women, minorities, veterans
and disabled employees to apply. Refusal to provide this information will have no bearing on your application and will
not subject you to any adverse treatment.

TO BE COMPLETED BY APPLICANT ON A VOLUNTARY BASIS, NOT FOR INTERVIEW PURPOSES, FILE SEPARATELY FROM APPLICATION.

Name:
Date:
Gender
MaleFemale
Position Applied For:

Race or Ethnicity Identity* (select one, see below for definitions)
Hispanic or LatinoWhite (not Hispanic or Latino)Black or African American (not Hispanic or Latino)Native Hawaiian or Pacific Islander (not Hispanic or Latino)Asian (not Hispanic or Latino)American Indian or Alaskan Native(not Hispanic or Latino)Two or more races (not Hispanic or Latino)

Veteran Status** (see below for definitions)
I am a protected veteranI am NOT a protected veteranI do not wish to self-identify

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