Bullock County Hospital

Employment Application Form:

(WE ARE AN EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER)
Your failure to fully and completely answer each inquiry on this application may disqualify you from consideration for employment
Personal Information:
Full Name*

First NameMiddle NameLast Name
Are you 18 years of age or older?*

YesNo
Phone Number*

Area CodePhone Number
Cell Number*

Area CodePhone Number
E-mail*
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Employment Desired:
Position Desired:
Days available to work:

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Shifts Available to work:

7am-7pm7pm-7amAny
Placement Desired:

Full-TimePart-TimeTemporary
Current Employment:
Current Employer
Name of Current Employer or NONE if not Employed
Start Date

MonthDayYear
Salary
Job Title
Phone Number:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for Leaving?
Duties:
Reason for Leaving (provide detailed response)
May We Contact?

YesNo
Previous Employment:

Please list the names of your previous employers in chronological order with present or last employer listed first. Include part-time and seasonal employment. Be sure to account for all periods of time, including military service and any period of unemployment. If self-employed, give company name and supply business references. You may also attach a detailed resume at the end of this application.
Previous Employer
Name of Previous Employer
Start Date

MonthDayYear
End Date

MonthDayYear
Ending Salary
Job Title
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last Supervisor's Name and Title
Duties
Reason for Leaving (provide detailed response)
Previous Employer
Name of Previous Employer
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Ending Salary
Job Title
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last Supervisor's Name and Title
Duties
Reason for Leaving (provide detailed response)
Previous Employer
Name of Previous Employer
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Ending Salary
Job Title
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last Supervisor's Name and Title
Duties
Reason for Leaving (provide detailed response)
Background Information
If hired, can you provide proof that you are legally entitled to work in the U.S.?*

YesNo
Have you ever worked for Bullock County Hospital?*

YesNo
If yes, please give dates and position:
Are you related to anyone currently employed by Bullock County Hospital?*

YesNo
If so, whom?
Have you ever been convicted of a criminal offense (felony or misdemeaner)?*

YesNo
Are any charges currently pending against you?*

YesNo
(NOTE: Answering “yes” to these questions does not constitute an automatic bar to employment). If you answered yes to any of the preceding questions, please give dates and details:
Education
High School
Years Completed

9101112
Diploma/Degree
Describe Course of Study or Magor
Describe Specialized Experience, Training, Skills, and Extra-Curricular Activities
College/University
Years Completed

1234
Diploma/Degree
Describe Course of Study or Major
Describe Specialized Experience, Training, Skills, and Extra-Curricular Activities
Graduate/Professional
Years Completed

1234
Diploma/Degree
Describe Course of Study or Major
Describe Specialized Experience, Training, Skills, and Extra-Curricular Activities
Personal References:
Reference 1
Name of Reference
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years Acquainted
Phone
Email
Reference 1
Name of Reference
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years Acquainted
Phone
Email
Reference 1
Name of Reference
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years Acquainted
Phone
Email
Applicant's Statement
I understand that Bullock County Hospital (the “Company”) is committed to providing equal opportunity in all employment practices, including but not limited to selection, hiring, promotion, transfer, and compensation to all qualified applicants and employees without regard to age, race, color, national origin, sex, religion, handicap or disability, or any other category protected by federal, state, or local law.

By my signature below I attest that the information given by me on this application is true and complete in all respects, and I agree that if the information is found to be false, misleading, incomplete, or unsatisfactory in any respect (as determined by Bullock County Hospital in its sole judgment) I will be disqualified from consideration for employment or subject to immediate dismissal if discovered after I am hired.

Thank you for submitting

Human Resource Department
Date*

MonthDayYear
Date
Signature*

Clear
Please verify that you are human*
THIS APPLICATION WILL BE CONSIDERED “ACTIVE” FOR A MAXIMUM OF THIRTY (30) DAYS. IF YOU WISH TO BE CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY.
Resume
Should be Empty:

Employment Application Form:

Personal Information:

Employment Desired:

Current Employment:

Previous Employment:

Background Information

Education

Personal References:

Applicant's Statement