Morgan Memorial Hospital - Employment Application

Application for EmploymentMorgan Memorial Hospital
1077 S. Main Street, P.O. Box 860, Madison, GA. 30650 706-342-1667

In accordance with the Drug Workplace Act of 1988, Morgan Memorial Hospital will not tolerate the usage of illegal drugs or alcohol in the work place. Morgan Memorial Hospital requires all employees to pass a pre-emplyment drug screen, a criminal records check and a motor vehicle license check.

Name:
Date:
Current Address:
Home Phone:
Cell Phone:
Work Phone:

List EACH place you have lived at any time in the past 5 years:	1	2	3
Dates
Address

Job Information
Position applying for:
Acceptable Salary:

Type Desired:	Full-TimePart-Time	SummerTemporaryOther

Shift willing to work:	7A/3P3P/11P11P/7A	7P/7A7A/7PWeekend Option

Are you willing to work weekends and/or holidays?	YesNo

When will you be available for work?

Skills/Qualifications:	Please list skills and/or supervisory qualifications that would correspond with the position applied for.
Typewriter WPM?	YesNo

Computer	YesNo

Dictaphone	YesNo

Med. Terminology	YesNo

List additional skills or experience:

Additional Personal Information
Are you under 18 years of age? (workers permit required if under 18yrs.)	YesNo

Are you a U.S. citizen or an Alien Legally authorized to work in the United States?	YesNo

If NO, type of Visa:

Have you ever been convicted of a felony?	YesNo

If YES please explain thoroughly:

Are you related to anyone employed at Morgan Memorial Hospital?	YesNo

If YES, who?
How were you referred to apply?

Education
High School:

Number of years completed:	1234

Name of School:

Address of School:

High School Diploma?	YesNo

Ged?	YesNo

College:

Number of years completed:	1234

Name of School:

Address of School:

Major:

Degree Earned:

Do you hold a:	PROFESSIONAL LICENSE, REGISTRATION, or CERTIFICATION
Type:
No.:
State:
Expiration Date:

References:	Required: 1 personal 2 work/professional
Name:
Address:
Phone Number:
Occupation/Organization:

Name:
Address:
Phone Number:
Occupation/Organization:

Name:
Address:
Phone Number:
Occupation/Organization:

Employment History:	Give complete records of all employment and/or reasons for periods of unemployment during the past 10 years. Begin with most recent employer.
Employer:
Date Worked:
Address:
Phone #:
Salary:
Reason for Leaving:

Employer:
Date Worked:
Address:
Phone #:
Salary:
Reason for Leaving:

Employer:
Date Worked:
Address:
Phone #:
Salary:
Reason for Leaving:

Employer:
Date Worked:
Address:
Phone #:
Salary:
Reason for Leaving:

Employer:
Date Worked:
Address:
Phone #:
Salary:
Reason for Leaving: