Stone County Hospital

Online Application

EMPLOYMENT APPLICATION

“A Tobacco-Free Employer”

Thank you for submitting your application for employment with Stone County Hospital, Inc. It is our policy to provide equal employment opportunities without regard to race, color, religion, sex, national origin, age, disability, or any other reason prohibited by law.

Name:

Social Security Number:

Address:

City:

State:

Zip:

Phone Number:

Alternate Phone Number:

Email Address:

Emergency Contact

Name:

Relationship:

Address:

Phone Number:

Are you at least 18 years old?

Are you a U.S. Citizen?

If you are not a citizen, can you provide adequate documents to establish your authorization to work in the U.S.?

Do you use any tobacco products?

Have you ever been convicted or found guilty of a misdemeanor or felony charge other than a traffic violation?
(Convictions will not necessarily bar you from employment, but are reviewed as related to the relevancy of the job applied for).

If yes, provide date, place and nature of incident.

Position(s) applying for:

Position 1

Position 2

Salary Desired

Date Available for Employment

Position Status Desired:  Full-time Part-time Temporary PRN

Shifts you can work:  Days Nights Weekends On-call

Have you ever been employed by Stone County Hospital
Or employed by Stone County Family Medical Clinic?

Have you ever been employed with any of the following facilities:

  • Stone County Nursing & Rehabilitation Center
  • Quest Rehab Services
  • Quest Medical Services
  • Stone County Ambulance
  • Greene County Ambulance

Do you have any relatives working for this facility?
If yes, provide name, relationship, and department

After a conditional offer, are you willing to undergo a physical exam/drug screen?

Military experience?

If yes, dates of service from to

Branch

Rank Obtained

Employment History

Please complete employment history even if resume is attached. List your employment history starting with your most recent job. Please attach a separate sheet of paper for additional employment.

Employer

Type of Business

Address

Phone number

Start Date

End Date

Supervisor's Name

Job Title

Final Rate of Pay

Job Duties

Reason For Leaving

Employer

Type of Business

Address

Phone number

Start Date

End Date

Supervisor's Name

Job Title

Final Rate of Pay

Job Duties

Reason For Leaving

Employer

Type of Business

Address

Phone number

Start Date

End Date

Supervisor's Name

Job Title

Final Rate of Pay

Job Duties

Reason For Leaving

May we contact your current employer?
No If no, please explain

Explain any lapses in employment (other than military service):

Skills

Indicate the following that you can apply:
 10-key calculator Pressure machine X-ray machine Computer Key punch machine Vital signs

List any other skills you possess:

Typing: Approximate WPM:

Shorthand: Approximate WPM:

Education

High School:

Location:

Did you earn a Diploma:

Did you earn a GED:

College or Technical School Location Degree Received Graduation Date

License/Certification

Type State Registration Number Expiration Date

References - List (3) three Business References

Name Job Title Company Name Phone Number

Please include any other information you think would be helpful to us in considering you for employment.
(You may exclude all information indicative of age, sex, religion, race, national origin or handicap).

I hereby affirm that the information on this application (and resume, if any) is true and complete to the best of my knowledge. I also agree that falsified information or significant omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date. I understand that my employment can be terminated, with or without cause, at any time at the discretion of the employer or myself. I understand that no management official other than the Chief Operating Officer of the employer has any authority or enter into agreement contrary to the foregoing or to make any oral assurance or promise of continued employment to me. I authorize persons, schools, my current employer (if applicable), and previous employers and organizations named in this application (and resume, if any) to provide any relevant information that may be required to arrive at an employment decision.

Resume: