Fulton County Hospital Application

Name*

First NameMiddle NameLast Name

Application Date*

Date that application is filled out.

Social Security Number*

Please enter your Social Security Number

Confirm Social Security Number*

Please Re-enter your Social Security Number

Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Home Phone

Please enter a valid phone number.

Cell Phone*

Please enter a valid phone number.

Email*

example@example.com

Referred By

First NameLast Name

High School

Please Enter High School you attended.

Diploma?

YesNo

Years Completed

Years of High School Completed

Trade School or Vocational School

Did you Graduate?

YesNo

Years Completed

Years of Vocational or Trade School Completed

Undergraduate College

Please Enter Undergraduate College you attended.

Did you graduate?

YesNo

Years Completed

Years of Undergraduate College Completed

Graduate / Professional School

Name of Graduate or Professional School you attended.

Did you graduate?

YesNo

Years Completed

Years of Graduate School or Professional School Completed

Other Education

Please Enter any other Education Institution

Did you graduate or complete program?

YesNo

Years Completed

Years of Other Education Completed

Describe any Specialized Training, Skills, or other Qualifications

Do you currently possess Licensure/Certification?*

YesNo

Are you eligible for Licensure/Certification?*

YesNo

If applicable, date you will sit for exam

Date

Have you ever been denied a professional or occupational license, registration, or certification?*

YesNo

Has your license, registration, or certification ever been investigated, revoked, suspended, restricted, or subject to any discipline by any board or government authority?*

YesNo

If yes to any of the questions above, please explain in detail.

Is CPR Certification Current?

YesNo

Is ACLS Certification Current?

YesNo

Position*

Position Desired

How many years of verifiable actual work experience do you have in the position you are applying for?

Number of years experience

Are you employed currently?*

YesNo

If yes, may we contact your present employer?*

YesNo

Dates you are available to work*

Date

Are you legally eligible to work in the United States?*

YesNo

Are you a Veteran?*

YesNo

Availability*

Full TimePart TimePRN (as needed)

Desired Wage*

Please Enter your Desired Wage

Have you ever applied to Fulton County Hospital before?*

YesNo

If Yes, what position?

Have you ever been employed by Fulton County Hospital?

YesNo

If Yes, what position?

Have you ever been convicted, pled guilty, pled nolo contender, or forfeited bond to a violation of an federal, state, parish/county, military service, municipal law, regulation or ordinance (including bad check/fraudulent check), other than minor traffic offenses? *Be certain to select "Yes" regardless of the severity of offense(s). Failure to do so will be considered falsification of application and can result in the withdrawal of an offer or termination of employment.

YesNo

Employer's name (Most Current)*

Position Held*

Supervisor's Name*

First NameLast Name

Employer's Phone Number*

Please enter a valid phone number.

Reason for Departure*

Duties*

Hourly Wage*

Start Date*

Date of Hire

End Date*

Date of Leave

Employer's Name

Position Held

Supervisor's Name

First NameLast Name

Employer's Phone Number

Please enter a valid phone number.

Reason for Departure

Duties

Hourly Wage

Start Date

Date of Hire

End Date

Date of Leave

Employer's Name

Position Held

Supervisor's Name

First NameLast Name

Employer's Phone Number

Please enter a valid phone number.

Reason for Departure

Duties

Hourly Wage

Start Date

Date of Hire

End Date

Date of Leave

Reference (1) Name*

First NameLast Name

Reference (1) Phone*

Please enter a valid phone number.

Reference (2) Name*

First NameLast Name

Reference (2) Phone*

Please enter a valid phone number.

Please upload your resume here.

PLEASE READ CAREFULLY BEFORE SIGNING

I certify that all the information on this application is accurate and complete to the best of my knowledge and understand that misleading or false statements will constitute sufficient cause for refusal of hire and termination of my employment. I understand that neither the acceptance of this application nor the subsequent entry into any type of employment with FULTON COUNTY HOSPITAL (FCH) creates an actual or implied contract of employment. I understand that, if I accept employment with FCH, it will be on an "at-will" basis. This means that either FCH or I have the right to terminate the employment relationship at any time, for any reason, with or without cause. I agree to submit to drug and alcohol testing, if requested by FCH. I release FCH and its employees, plus other persons or companies, from any and all liability arising out of or related in any way to such testing. I understand that employees of FCH are considered to be in security-sensitive positions or positions of trust which authorizes FCH to obtain criminal record history information. I authorize FCH to investigate information concerning my education, employment experiences, and all other aspects of my background relevant to my proposed employment. I release FCH and its employees and all prior employees from liability that may potentially result from the release and/or use of such information given in good faith. Any doctor, hospital, or testing laboratory has my consent to conduct medical and drugs tests on me, and I hereby give my consent to having all information released to FCH in order to determine my abilities to perform job duties now or in the future. I understand that FCH requires all staff to report sanctions, convictions, suspensions, censures, or revocation action taken against them by federal, state, local, or other professional entities. These sanctions may include but are not limited to infractions against professional licensure, criminal convictions, child or elder abuse, etc. This application is current and active for only six months. At the conclusion of that time, if I have not had any contact from FCH and still wish to be considered for employment, it will be necessary for me to complete a new employment application. If employed, I understand that I must abide by FCH's policies and procedures.

Signature

Please enter the message as it is shown.*

After clicking the submit button, please scroll up to verify that your application has been submitted successfully. If you are unable to successfully submit your application, please call (870) 895-6013.

Gender*

Race / Ethnicity (the following definitions are taken from the Equal Employment Opportunity Commission (EEOC); please select the one that most closely represents your race/ethnicity):*

American Indian or Alaskan Native - a person with origins in any of the original peoples of North America and who maintains cultural identification through tribal affiliations or community recognition.Asian - a person with origins in any of the original people of the Far East, Southeast Asia, or the Indian subcontinent. Also included are the countries of China, Japan, Korea, the Philippine Islands, and Samoa. The Indian subcontinent includes: Bangladesh, Bhutan, India, Nepal, Pakistan, Sikkim, and Sri Lanka.Black or African American - a person with origins in any of the black racial groups of Africa who is not of Hispanic origin.Hispanic or Latino - a person of Mexican, Puerto Rican, Cuban, South American, or other Spanish culture or origin, regardless of race.Native Hawaiian or other Pacific IslanderTwo or more RacesWhite / Caucasian - a person with origins in any of the original peoples of Europe, North Africa, or the Middle East who is not of Hispanic origin.Choose not to disclose

Fulton County Hospital Application

PERSONAL INFORMATION

EDUCATION

LICENSURE AND CERTIFICATION

EMPLOYMENT DESIRED

EMPLOYMENT EXPERIENCE

PLEASE LIST TWO REFERENCES OTHER THAN RELATIVES OR PREVIOUS EMPLOYERS

RESUME

I have read and agree to the above and hereby certify that the information that I have provided in my employment application is true and complete

Equal Employment Opportunity Disclosure / Voluntary Self Identification