Job Application: Director of Home Health

Title: Director of Home Health

Fields marked with an asterisk (*) must be filled out before submitting.

Personal Details

First Name *
Last Name *
Position Applying For *
Address *
City *
State *
Zip Code *
Cell phone *
Day Telephone *
Last four of your SSN
Do you have experience? * Yes
No
 
Will you accept Full Time work? * Yes
No
 
Will you accept Part Time Work? * Yes
No
 
Will you accept Temporary Work? * Yes
No
 
Can you work Days? * Yes
No
 
Can you work Nights? * Yes
No
 
Can you work Weekends? Yes
No
Date you can begin work?
Have you worked at EMC before? * Yes
No
If so, when?
Under what name?
Reason you left?
Names of Relatives that work at EMC? *
Have you ever been convicted of a Felony? Explain *

Employment History

Most Recent Employer Company Name *
Company Phone *
Position Held and Description of Duties *
Dates of Employment *
Reason for Leaving *
Beginning Pay *
Ending Pay *
 
Company Name
Company Phone
Position Held and Description of Duties
Dates of Employment
Beginning Pay
Ending Pay
Reason for Leaving
 
Company Name
Company Phone
Position Held and Description of Duties
Dates of Employment
Beginning Pay
Ending Pay
Reason for Leaving
Please List Other Jobs:

Skills

Special Skills
Do you know Medical Terminology? * Yes
No
Approximate Words Per Minute (Typing)

Education

College Name and Location
Course of Study
Number of Years Completed
Did you graduate? Yes
No
Certification Degree or Diploma:
 
High School Name and Location
Course of Study
Number of years completed
Did you graduate? Yes
No
Certification Degree or Diploma
 
Are you currently enrolled in school? * Yes
No
If so, where?
Major:
Approximate graduation date/year:

Professional Licenses and Certifications

License Type *
Number
Original Date Issued
State
Expiration

Personal References (Not Relatives or Former Employers)

Name *
Phone Number *
Occupation *
 
Name *
Phone Number *
Occupation *
Name *
Phone Number *
Occupation *

Other Information

Are you at least 19 years of age? * Yes
No
Do you have a valid Alabama driver\\\’s license? * Yes
No
License Number
Have you ever been discharged (fired) or asked to resign from a job? * Yes
No
If yes, explain
* I have made application for employment at Evergreen Medical Center and authorize all former employers to release information pertaining to employment history, attendance records, and work performance while in their employment.
* I also authorize my present employer to release information pertaining to employment history, attendance records, and work performance while I have been in their employment.
* I hereby state that the information given by me is true in all respects. I also agree that if I am employed and the information is found to be false in any respect, I will be subject to dismissal without notice at anytime.
 

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