PERSONAL DATA |
| Name (Last, First, M.I.)
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Position Desired
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| Address
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Type of Position
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| City, State, Zip
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Willing to work Evenings?
Willing to work Nights?
Willing to work Weekends?
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Telephone
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Social Security
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If offered employment, date you would be available to start work:
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Date of Birth
The Age Discrimination in Employment Act prohibits discrimination on the basis of age with respect to individuals who are at least 40, but less than 70 years of age. |
Will you take a physical exam?
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SELECTIVE SERVICE DATA |
| Have you ever been in the U.S. Military Service?
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Date of Service:
From:
To:
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| Service Schools:
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| EDUCATIONAL DATA |
| Name and Address of High School |
Course or Major |
Dates Attended |
Graduate? |
Date |
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From:
To:
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From:
To:
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| Name and Address of College |
Course or Major |
Dates Attended |
Graduate? |
Date |
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From:
To:
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From:
To:
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| Name and Address of Business, Technical, or Professional School(s) attended |
Course or Major |
Dates Attended |
Graduate? |
Date |
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From:
To:
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From:
To:
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| Professional License/Registry/Certification #/Other Special Training
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| SPECIAL SKILLS AND INTERESTS |
| List any maintenance or Shop Equipment or Office Machines You Operate:
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| Do you type?
WPM?
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| Professional organizations, interests, hobbies (omit any which might indicate race, religion, color, national origin, or ancestry)
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| EMPLOYMENT DATA |
| Begin with your most recent job: |
DATES OF EMPLOYMENT (Give Month and Year)
From
To
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Employer's Name |
Salary Starting
Ending
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Duties
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| Employer's Address |
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| Supervisor's Name |
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| Reason for Leaving |
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May we contact your current employer?
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From
To
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Employer's Name |
Salary Starting
Ending
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Duties
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| Employer's Address |
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| Supervisor's Name |
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| Reason for Leaving |
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May we contact your current employer?
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From
To
|
Employer's Name |
Salary Starting
Ending
|
|
Duties
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| Employer's Address |
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| Supervisor's Name |
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| Reason for Leaving |
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May we contact your current employer?
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| Have you worked for Bibb Medical Center before?
If Yes, give date From:
To:
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| Name of relatives employed by Bibb Medical Center
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| GIVE NAME AND ADDRESS OF PERSON TO NOTIFY IN CASE OF EMERGENCY: |
| Name:
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Phone:
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Number & Street:
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| City, State, and Zip:
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| MISCELLEANEOUS INFORMATION |
Have you ever been convicted of a felony?
If yes, list offenses:
Date of conviction:
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| Have you ever been refused a surety bond?
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| NOTE: An answer of yes to either of the above questions does not necessarily disqualify you for employment at Bibb Medical Center. |
CERTIFICATION OF APPLICANT
THE INFORMATION GIVEN IN THIS APPLICATION IS GIVEN OF MY OWN FREE WILL AND ACCORD AND IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. THIS IS MY EXPRESS PERMISSION FOR BIBB MEDICAL CENTER TO CONDUCT AN INVESTIGATION INTO MY BACKGROUND, EXPERIENCE, QUALIFICATIONS, ETC. I FULLY UNDERSTAND THAT, AS A CONDITION OF EMPLOYMENT, IW ILL BE REQUIRED TO TAKE A PHYSICAL EXAMINATION AND THE INTERPRETATION OF THE RESULTS OF SUCH EXAMINATION SHALL BE MADE BY BIBB MEDICAL CENTER, IN ACCORDANCE WITH THE REHABILITATION ACT OF 1973. I FULLY UNDERSTAND THAT THE PERSONAL AND FAMILY MEDICAL RECORD FORM WILL BE KEPT CONFIDENTIAL, EXCEPT TO THE EXTENT THAT DISCLOSURE MAY BE REQUIRED IN ORDER TO COMPLY WITH THE REQUIRED IN ORDER TO COMPLY WITH TH EREHABILITATION ACT OF 1973 OR ENSURE MY SAFETY OR THAT OF OTHER EMPLOYEES. ANY FALSE STATEMENT HEREON, OR ANY WITHHOLDING OF REQUESTED INFORMATION WILL BE SUFFICIENT CAUSE FOR REJECTION OR TERMINATION. I FURTHER UNDERSTAND THAT THIS STATUS CAN ONLY BE ALTERED BY A WRITTEN CONTRACT OF EMPLOYMENT WHICH IS SPECIFIC AS TO ALL MATERIAL TERMS AND IS SIGNED BY BOTH ME AND THE ADMINISTRATOR OF BIBB MEDICAL CENTER.
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| Do you certify that the above information is accurate (equivalent to signature)?
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