Click for Evergreen, Alabama Forecast

Please read carefully-answer all questions. All areas of the application must be completely filled out to be considered for employment.

The questions found in this form are being asked to properly evaluate your ability and chance for success in the position for which you are applying. Every effort has been made to comply with the Applicable Federal Law and Laws of our State. It is not our intent to discriminate in employment on account of color, race, sex, religion, age, National origin or handicap.
Name:
Other Names under which you may have worked:
Street Address:
City:
State:
Zip Code:
Home Phone:
How is this number listed?
Phone where you may be reached during the day:
Position Desired:
Do you have experience?
Position applying for:
Do you have experience?
Social Security Number:
Have you ever worked at Evergreen Medical Center? Yes   No 
If so, when?
Under what name?
Reason for leaving?
Do you now or have you ever had any relatives who worked for this hospital? Yes   No 
If yes, complete the following:
Name:
Relationship:
Name:
Relationship:
Can you get to work on time as scheduled and when called in on short notice? Yes   No 
Date you can begin work?
Shift hours preferred:
Can you work:       
Days? Yes   No 
Evenings? Yes   No 
Nights? Yes   No 
Weekends? Yes   No 
Will you accept full time work?  Yes   No 
Will you accept part time work?  Yes   No 
Will you accept temporary work?  Yes   No 
Will you work over-time when scheduled?  Yes   No 
Have you ever been convicted of a felony?  Yes   No 
If yes, explain:
Do you have a legal right to live and work in the USA? Yes   No 
Are you obligated in any way to another organization as a scholarship recipient? Yes   No

Employment History

Please give accurate, complete, full time and part time employment record. Start with your present or most recent employer.
Company Name:
Telephone:
Address:
Name of Supervisor:
State Job Title and describe your work:
Employed (Month and Year)
From: To:
Hourly Rate of Pay $ per hour
Start: Last:
Shift Pay: $ per hour
Call Pay: $ per hour
Reason for leaving:
Company Name:
Telephone:
Address:
Name of Supervisor:
State Job Title and describe your work:
Employed (Month and Year)
From: To:
Hourly Rate of Pay: $ per hour
Start: Last:
Shift Pay: $ per hour
Call Pay: $ per hour
Reason for leaving:
Company Name:
Telephone:
Address:
Name of Supervisor:
State Job Title and describe your work:
Employed (Month and Year)
From: To:
Hourly Rate of Pay $ per hour
Start: Last:
Shift Pay: $ per hour
Call Pay: $ per hour
Reason for leaving:
Please list other jobs below:
Are you willing to take a physical exam at our expense?
Special Skills:
Machines, office equipment, and/or hospital equipment you can operate:
Do you know medical terminology?
Typing: Approximate WPM:
Shorthand: Approximate WPM:
Computer: Approximate WPM:

Education
College name and location
Course of study:
Number of years completed:
Did you graduate? Yes   No 
Certification degree or diploma:
High School name and location  
Course of study:  
Number of years completed:
Did you graduate? Yes   No 
Certification degree or diploma:
Elementary School name and location
Course of study:
Number of years completed:
Did you graduate? Yes   No 
Certification degree or diploma:
Other, name and location
Course of study:
Number of years completed:
Did you graduate? Yes   No 
Certification degree or diploma:  
Are you currently enrolled in school? Yes   No 
If yes, where?
Major:
Approximate graduation date/year:
Professional Licenses and Certifications
Type:
Original date issued: (DDMMYYYY)
Number:
State:
Expiration: (MMYY)
Type:
Original date issued: (DDMMYYYY)
Number:
State:
Expiration: (MMYY)
Are you at least 19 years of age? Yes   No 
Do you have a valid Alabama driver's license? Yes   No 
License #:
Personal References (Not relatives of former employers)
Name:
Address:
Occupation:
Phone:
Name:
Address:
Occupation:
Phone:
Name:
Address:
Occupation:
Phone:
Have you ever been discharged (fired) or asked to resign from a job? Yes   No 
If yes, explain:
Evergreen Medical Center is a drug free work environment. Prior to employment, a drug test is required. Random drug testing is a part of our substance abuse policy and all employees are to adhere to this policy.
I have made application for employment at Evergreen Medical Center and authorize all former employees to release information pertaining to employment history, attendance records, and work performance while in their employment.
Full Name:
Date:
I also authorize my present employer to release information pertaining to employment history, attendance records, and work performance while I have been in their employment.
Full Name:
Date:
I hereby state that the information given my me is true in all respects. I also agree that if I am employed and the information is found to be false in any respect, I will be subject to dismissal without notice at anytime.
Full Name:
Date:
Who may we notify in case of an emergency?
Name:
Phone:
Relation: