Application for Registration Clerk

1050 Valdosta Highway / Homerville, GA 31634 View phone number on click.appcast.io APPLICATION FOR EMPLOYMENT Date: _______________________________ This institution is an equal opportunity provider and employer. DFWP 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? Yes No 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 DATA 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 Later Dates of Employment: From: To: Employer’s Address Telephone# Supervisor’s Name: Title Duties Reason for Leaving Email address Starting Salary Ending Salary Employer’s Name May We Contact? Yes No Later Dates of Employment: From: To: Employer’s Address Telephone# Supervisor’s Name: Title Duties Reason for Leaving Email address Starting Salary Ending Salary Employer’s Name May We Contact? Yes No Later Dates of Employment: From: To: Employer’s Address Telephone# Supervisor’s Name: Title Duties Reason for Leaving Email address Starting Salary Ending Salary - - - 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_______ IFICATION OF APPLICANT CERT 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 result in the may 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 unl are in writing and signed by the employer’s administrator. ess they I also understand that if I am hire , I will be required to provide proof of identity and legal authorization to work in the United d 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 al 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. I understand that refusal to submit to a drug test or a positive test result may preclude my application from further consideration. I further understand that Clinch Memorial Hospital reserves the right to require its employees to submit to bl od tests or urinalysis for o alcohol or drug screens, or to allow inspection of bags (including purses or brief cases) or parcels brought into or taken out of Clinch Memorial Hospital. I understand that, if employed, a positive test result or a refusal to submit to a urinalysis, blood test or search, when requested to do so may result in termination of my employment. Clinch Memorial Hospital does not tolerate unlawful discrimination in its emp n this application is loyment practice. No question o used for purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex the (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. D O NOT SIGN UNTIL YOU HAVE READ THIS ABOVE CERTIFICATION OF APPLICANT. I certify that I have read, fully understand and accept all terms of the foregoing Certification Applicant. of Signature of Applicant______________________________________________________ Date: INTERVIEWER NOTES 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. 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, see back for definitions) Hispanic or Latino White (not Hispanic or Latino) Black or African American (not Hispanic or Latino) Native Hawaiian or Pacific Islander (not Hispanic or Latino) Asian (not Hispanic or Latino) American Indian or Alaskan 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 advertisement - please explain___________________ recruiter other - please explain:________________ For Administrative Use Position(s) applied for_________________________________________ Current opening No current opening Hired? No Yes Hire date__________________ Position classification Office and clerical Workers Sales Workers Technicians Operatives (semi-skilled) Service Workers Laborers (unskilled) Craft Workers (skilled) Professionals Official and Managers *EEOC RACE/ETHNIC IDENTIFICATION CATEGORIES Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. White (not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East or North Africa. Black or African American (not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander (not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands. Asian (not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam. American Indian or Alaska Native (not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment. Two or more races (not Hispanic or Latino) - All persons who identify with more than one of the above races. **PROTECTED VETERAN DEFINITION Protected veteran means a veteran who may be classified as an active duty wartime or campaign badge veteran, disabled veteran, Armed Forces service medal veteran or recently separated veteran. Active duty wartime or campaign badge veteran means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense. Armed Forces service medal veteran means any veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985 (61 FR 1209, 3 CFR, 1996 Comp., p. 159). Disabled veteran means (1) a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs, or (2) a person who was discharged or released from active duty because of a service-connected disability. Recently separated veteran means a veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval or air service. #J-18808-Ljbffr Clinch Memorial Hospital