Clinch Memorial Hospital
Application for Medical Technologist – (MT) Night Shift - 6p - 6a & Rotating Wee
Clinch Memorial Hospital, Homerville, Georgia, United States, 31634
Overview
Clinch Memorial Hospital is an equal opportunity employer. This institution is an equal opportunity provider and employer. APPLICATION FOR EMPLOYMENT Date: _______________________________
Personal Data
Last Name
First Name
Middle Name
Maiden Name
Current Address
Number and Street
City
State
Zip Code
Social Security Number (Last four digits) XXX-XX-
Previous Address
Number and Street
City
State
Zip Code
Telephone Number
Are you at least 18?
Position Desired
Desired Salary
Full Time
Part Time
Temp
Willing to work?
Evening Yes No
Night Yes No
Weekends Yes No
Email Address
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
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
Education
Name and Address of High School
Dates Attended
Graduate?
Date
Name and Address of College
Course or Major
Dates Attended
Graduate?
Degree
Name and Address of Other Course or Major
Dates Attended
Graduate?
Degree or Diploma
Personal References
Name and Address
Telephone Number
Email Address
Name and Address
Telephone Number
Email Address
Name and Address
Telephone Number
Email Address
Employment Data Begin with your most recent job.
Employer’s Name
May We Contact? Yes No
Dates of Employment: From To
Employer’s Address
Telephone#
Supervisor’s Name
Title
Duties
Reason for Leaving
Email address
Starting Salary
Ending Salary
Additional employment entries may be included as needed.
Skills
List Number and Expiration Date of any Professional Occupational License
State Driver’s License #(Last four digits)
Are You Computer Literate? What Software?
Typing speed?
Office Equipment?
Have you ever worked for Clinch Memorial Hospital before? Yes No
If yes, give dates: From ________ To _______
Certification of Applicant
I hereby state that the information given by me in the application is complete and true in all respects.
I understand that any omission, misrepresentation, or falsification will preclude my application from further consideration.
I further understand that if employed, the subsequent disclosure of any omission, misrepresentation, or falsification of information may result in termination of my employment.
If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law.
This application does not constitute an agreement or contract for employment for any specified period or definite duration.
I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreement contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s administrator.
I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.
I understand that reasonable safeguards will be taken to protect all personal information provided or obtained in conjunction with this application for employment. My personal information may be shared with the employer’s affiliate(s) and third parties engaged by the employer to perform services for the employer. Any person information shared with an affiliate or third party is also to be used solely to perform the services requested by the employer.
I understand that Clinch Memorial Hospital reserves the right to require its applicants to submit to a drug test. Refusal to submit to a drug test or a positive test result may preclude my application from further consideration. Clinch Memorial Hospital reserves the right to require its employees to submit to blood tests or urinalysis for alcohol or drugs, or to allow inspection of bags or parcels brought into or taken out of Clinch Memorial Hospital. A positive test result or a refusal to submit to a urinalysis, blood test or search, when requested, may result in termination of my employment.
Clinch Memorial Hospital does not tolerate unlawful discrimination in its employment practices. No question used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of sex (including pregnancy), race, color, religion, national origin, citizenship, age, disability, genetic information, or any other protected status under applicable federal, state, or local law.
I hereby authorize Clinch Memorial Hospital to make all necessary and appropriate investigations to verify the information contained herein including a report of prior convictions and authorize my former employers to release information pertaining to my work record, my work habits, and my work performance while in their employ.
DO NOT SIGN UNTIL YOU HAVE READ THIS CERTIFICATION OF APPLICANT ABOVE. I certify that I have read, fully understand and accept all terms of the foregoing Certification Applicant.
Signature of Applicant: __________________________ Date: ____________
INTERVIEWER NOTES
Affirmative Action Clinch Memorial Hospital is an equal opportunity employer. As required by law, we must record certain information to be made a part of our affirmative action program. Applicants for employment are invited to participate in the affirmative action program by reporting their status as a protected veteran or other minority. In extending this invitation, we advise you that: (a) workers (applicants) are under no obligation to respond but may do so in the future if they choose; (b) responses will remain confidential within the human resource department; and (c) responses will be used only for the necessary information to include in our affirmative action program.
We are a company that values diversity. We actively encourage women, minorities, veterans and disabled employees to apply. Refusal to provide this information will have no bearing on your application and will not subject you to any adverse treatment.
Voluntary Information TO BE COMPLETED BY APPLICANT ON A VOLUNTARY BASIS, NOT FOR INTERVIEW PURPOSES, FILE SEPARATELY FROM APPLICATION.
Name: __________________________ Date: ____________
Gender: Male Female
Position Applied for: ________________________
Race or Ethnicity Identity (select one):
Hispanic or Latino
White (not Hispanic or Latino)
Black or African American (not Hispanic or Latino)
Native Hawaiian or Other Pacific Islander (not Hispanic or Latino)
Asian (not Hispanic or Latino)
American Indian or Alaska Native (not Hispanic or Latino)
Two or more races (not Hispanic or Latino)
Veteran Status (see back for definitions)
I am a protected veteran / I am NOT a protected veteran / I do not wish to self-identify
How did you hear of our opening?
employee referral, company website, job board, social media (please explain), recruiter, other (please explain)
For Administrative Use: Position(s) applied for, Current opening, Hired? Yes/No, Hire date
Position classification: Office and clerical; Workers; Sales; Technicians; Operatives (semi-skilled); Service Workers; Laborers (unskilled); Craft Workers (skilled); Professionals; Official and Managers
*EEOC RACE/ETHNIC IDENTIFICATION CATEGORIES and **PROTECTED VETERAN DEFINITION are provided for voluntary disclosure.
Note: The information in this document is a sanitized reproduction of a paper employment application. All content remains as provided; formatting adapted for structured display.
#J-18808-Ljbffr
Clinch Memorial Hospital is an equal opportunity employer. This institution is an equal opportunity provider and employer. APPLICATION FOR EMPLOYMENT Date: _______________________________
Personal Data
Last Name
First Name
Middle Name
Maiden Name
Current Address
Number and Street
City
State
Zip Code
Social Security Number (Last four digits) XXX-XX-
Previous Address
Number and Street
City
State
Zip Code
Telephone Number
Are you at least 18?
Position Desired
Desired Salary
Full Time
Part Time
Temp
Willing to work?
Evening Yes No
Night Yes No
Weekends Yes No
Email Address
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
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
Education
Name and Address of High School
Dates Attended
Graduate?
Date
Name and Address of College
Course or Major
Dates Attended
Graduate?
Degree
Name and Address of Other Course or Major
Dates Attended
Graduate?
Degree or Diploma
Personal References
Name and Address
Telephone Number
Email Address
Name and Address
Telephone Number
Email Address
Name and Address
Telephone Number
Email Address
Employment Data Begin with your most recent job.
Employer’s Name
May We Contact? Yes No
Dates of Employment: From To
Employer’s Address
Telephone#
Supervisor’s Name
Title
Duties
Reason for Leaving
Email address
Starting Salary
Ending Salary
Additional employment entries may be included as needed.
Skills
List Number and Expiration Date of any Professional Occupational License
State Driver’s License #(Last four digits)
Are You Computer Literate? What Software?
Typing speed?
Office Equipment?
Have you ever worked for Clinch Memorial Hospital before? Yes No
If yes, give dates: From ________ To _______
Certification of Applicant
I hereby state that the information given by me in the application is complete and true in all respects.
I understand that any omission, misrepresentation, or falsification will preclude my application from further consideration.
I further understand that if employed, the subsequent disclosure of any omission, misrepresentation, or falsification of information may result in termination of my employment.
If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law.
This application does not constitute an agreement or contract for employment for any specified period or definite duration.
I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreement contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s administrator.
I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.
I understand that reasonable safeguards will be taken to protect all personal information provided or obtained in conjunction with this application for employment. My personal information may be shared with the employer’s affiliate(s) and third parties engaged by the employer to perform services for the employer. Any person information shared with an affiliate or third party is also to be used solely to perform the services requested by the employer.
I understand that Clinch Memorial Hospital reserves the right to require its applicants to submit to a drug test. Refusal to submit to a drug test or a positive test result may preclude my application from further consideration. Clinch Memorial Hospital reserves the right to require its employees to submit to blood tests or urinalysis for alcohol or drugs, or to allow inspection of bags or parcels brought into or taken out of Clinch Memorial Hospital. A positive test result or a refusal to submit to a urinalysis, blood test or search, when requested, may result in termination of my employment.
Clinch Memorial Hospital does not tolerate unlawful discrimination in its employment practices. No question used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of sex (including pregnancy), race, color, religion, national origin, citizenship, age, disability, genetic information, or any other protected status under applicable federal, state, or local law.
I hereby authorize Clinch Memorial Hospital to make all necessary and appropriate investigations to verify the information contained herein including a report of prior convictions and authorize my former employers to release information pertaining to my work record, my work habits, and my work performance while in their employ.
DO NOT SIGN UNTIL YOU HAVE READ THIS CERTIFICATION OF APPLICANT ABOVE. I certify that I have read, fully understand and accept all terms of the foregoing Certification Applicant.
Signature of Applicant: __________________________ Date: ____________
INTERVIEWER NOTES
Affirmative Action Clinch Memorial Hospital is an equal opportunity employer. As required by law, we must record certain information to be made a part of our affirmative action program. Applicants for employment are invited to participate in the affirmative action program by reporting their status as a protected veteran or other minority. In extending this invitation, we advise you that: (a) workers (applicants) are under no obligation to respond but may do so in the future if they choose; (b) responses will remain confidential within the human resource department; and (c) responses will be used only for the necessary information to include in our affirmative action program.
We are a company that values diversity. We actively encourage women, minorities, veterans and disabled employees to apply. Refusal to provide this information will have no bearing on your application and will not subject you to any adverse treatment.
Voluntary Information TO BE COMPLETED BY APPLICANT ON A VOLUNTARY BASIS, NOT FOR INTERVIEW PURPOSES, FILE SEPARATELY FROM APPLICATION.
Name: __________________________ Date: ____________
Gender: Male Female
Position Applied for: ________________________
Race or Ethnicity Identity (select one):
Hispanic or Latino
White (not Hispanic or Latino)
Black or African American (not Hispanic or Latino)
Native Hawaiian or Other Pacific Islander (not Hispanic or Latino)
Asian (not Hispanic or Latino)
American Indian or Alaska Native (not Hispanic or Latino)
Two or more races (not Hispanic or Latino)
Veteran Status (see back for definitions)
I am a protected veteran / I am NOT a protected veteran / I do not wish to self-identify
How did you hear of our opening?
employee referral, company website, job board, social media (please explain), recruiter, other (please explain)
For Administrative Use: Position(s) applied for, Current opening, Hired? Yes/No, Hire date
Position classification: Office and clerical; Workers; Sales; Technicians; Operatives (semi-skilled); Service Workers; Laborers (unskilled); Craft Workers (skilled); Professionals; Official and Managers
*EEOC RACE/ETHNIC IDENTIFICATION CATEGORIES and **PROTECTED VETERAN DEFINITION are provided for voluntary disclosure.
Note: The information in this document is a sanitized reproduction of a paper employment application. All content remains as provided; formatting adapted for structured display.
#J-18808-Ljbffr