Form
Personal Information
Name:
*
First Name
Middle Name
Last Name
Are you at least 18 years old?
*
Yes
No
Social Security Number
*
Main Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address:
*
example@example.com
Present Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Previous Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Professional Information
If there are any specific positions you are applying for, please list them here:
Type of Position (Mark All That Apply):
*
Per Diem
Pool
Full-time
PRN
Part-time
Temporary
Shift (Mark All That Apply):
*
Weekend
Day
Night
Evening
Rotation
Salary Requirement:
Are you willing to travel?
Yes
No
Are you willing to relocate?
Yes
No
Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?
Yes
No
If overtime work is required periodically, does this pose a problem for you?
Yes
No
Are you legally authorized to work in the U.S.?
*
Yes
No
Have you ever worked in any Greenwood County Hospital facility?
Yes
No
What facility?
Are you related to another Greenwood County Hospital facility employee?
Yes
No
Date Available For Work:
If you are applying for a specific position, how did you learn about it?
State Employment
Commission
Internet
Agency
Ad
Job Listing
School
Current Employee
Job Line
Other
Are you able to perform the essential, job-related functions of the position for which you are applying with or without reasonable accommodations?
*
Yes
No
Describe any accommodations necessary:
Have you been convicted of a crime and/or released from confinement following a conviction for any criminal offense? (Arrests or charges that have been expunged need not be disclosed.)
*
Yes
No
Please provide the date, place and nature of each such event:
*
Are you presently charged with any violation of the law?
*
Yes
No
Please provide the date, place and nature of each such event:
*
Are you currently excluded from participation in any federally funded healthcare program, including Medicare and Medicaid, and are you aware of any potential exclusion from a federally funded health program?
*
Yes
No
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Professional License/Registration or Certification
First Professional License/Registration or Certification
Type:
State Issued:
Expiration Date:
Number:
Second Professional License/Registration or Certification
Type:
State Issued:
Expiration Date:
Number:
Third Professional License/Registration or Certification
Type:
State Issued:
Expiration Date:
Number:
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Education & Skills
High School Name:
*
High School City:
*
High School State:
*
Select Last Year High School Attended:
*
9
10
11
12
Did you graduate or obtain a GED?
*
Yes
No
College Name:
College City:
College State:
How many years did you attend this college?
1
2
3
4
Did you graduate from this college?
Yes
No
Did you obtain a degree from this college?
Yes
No
Please specify the degree:
Secondary College Name:
Secondary College City:
Secondary College State:
How many years did you attend this secondary college?
1
2
3
4
Did you graduate from this secondary college?
Yes
No
Please specify the secondary college degree:
Graduate Name:
Graduate School City:
Graduate School State:
How many years did you attend this graduate school?
1
2
3
4
Did you graduate from this graduate school?
Yes
No
Please specify the graduate school degree:
First Additional School Name:
First Additional School City:
First Additional School State:
How many years did you attend this first additional school?
1
2
3
4
Did you graduate from this first additional school?
Yes
No
Please specify the first additional school degree:
Second Additional School Name:
Second Additional School City:
Second Additional School State:
How many years did you attend this second additional school?
1
2
3
4
Did you graduate from this second additional school?
Yes
No
Please specify the second additional school degree:
Typing Speed in Words Per Minute (WPM):
PBX:
Please list any position-related software proficiencies:
Please list business machines or equipment you can operate:
Additional Applicable Skills:
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Employment
Most Recent Previous Employment
Most recent previous employment start date:
*
Most recent previous employment end date:
*
Most recent previous employers name:
*
Most recent previous employers phone number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Most recent previous employment immediate supervisor:
*
May we contact your most recent previous employer?
*
Yes
No
Most recent previous employment salary:
*
Most recent previous employer address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name while employed at most recent previous employer:
*
What was your job title while employed by your most recent employer?
*
What was your shift while employed by your most recent employer?
*
How many hours per week did you work while employed by your most recent employer?
*
Reason for leaving your most recent employer:
*
Second Most Recent Previous Employment
Second most recent previous employment start date:
Second most recent previous employment end date:
Second most recent previous employers name:
Second most recent previous employers phone number:
Please enter a valid phone number.
Format: (000) 000-0000.
Second most recent previous employment immediate supervisor:
May we contact your second most recent previous employer?
Yes
No
Second most recent previous employment salary:
Second most recent previous employer address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name while employed at second most recent previous employer:
What was your job title while employed by your second most recent employer?
What was your shift while employed by your second most recent employer?
How many hours per week did you work while employed by your second most recent employer?
Reason for leaving your second most recent employer:
Third Most Recent Previous Employment
Third most recent previous employment start date:
Third most recent previous employment end date:
Third most recent previous employers name:
Third most recent previous employers phone number:
Please enter a valid phone number.
Format: (000) 000-0000.
Third most recent previous employment immediate supervisor:
May we contact your third most recent previous employer?
Yes
No
Third most recent previous employment salary:
Third most recent previous employer address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name while employed at third most recent previous employer:
What was your job title while employed by your third most recent employer?
What was your shift while employed by your third most recent employer?
How many hours per week did you work while employed by your third most recent employer?
Reason for leaving your third most recent employer:
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References
First Professional Reference
First Professional Reference Name:
*
First Name
Last Name
First Professional Reference Position:
*
First Professional Reference Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
First Professional Reference Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
First Professional Reference Number of Years Known:
*
Second Professional Reference
Second Professional Reference Name:
*
First Name
Last Name
Second Professional Reference Position:
*
Second Professional Reference Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Second Professional Reference Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Second Professional Reference Number of Years Known:
*
Third Professional Reference
Third Professional Reference Name:
*
First Name
Last Name
Third Professional Reference Position:
*
Third Professional Reference Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Third Professional Reference Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Third Professional Reference Number of Years Known:
*
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Finish and Submit
Release Authorization Full Name:
*
First Name
Middle Name
Last Name
Release Authorization Maiden or Other Name(s) Used:
*
Release Authorization Drivers License Number:
*
Release Authorization Date of Birth:
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Release Authorization Sex:
*
Male
Female
Not Applicable
Release Authorization Current Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I understand that by checking the following box and typing my name into the name field above, this document is as valid as if I have signed it.
*
I agree
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