Macon County General Hospital
Working for Your Better Health

Please Read Carefully - Answer All Questions

Macon County General Hospital Complies With Federal and State Laws that Prohibit Discrimination in Employment Because of Race, Color, Creed, Age, Sex, Martial Status, National Origin, Physical Handicap, Medical Condition or Sexual Orientation.

Date

Name

First Last

Email

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Position Desired

Status

Shift Preference

Have you worked for us before?

Under another name? (Please list)

Citizenship (Please state)

Are/were you in the U.S. Military Service?

Related experience

Can you perform the essential functions of the position you are applying for safely?

Are you willing to take a required pre-employment drug screen?

Are you willing to take a required pre-employment physical?

Have you ever been excluded from or sanctioned by the Medicare program?

Have you since the age of 18 been convicted of a felony?

Do you object to a required background check?

Have you ever been involuntarily discharged from a job?

EDUCATION INFORMATION

High School attended

Did you receive a high school diploma?

College or University attended

Did you receive a college degree?

Technical or Vocational School

Did you receive a technical or vocational degree?

List any other education

PAST/CURRENT EMPLOYMENT INFORMATION

Employer name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Dates of employment

Position

Salary

Reason for leaving

Can we contact your current employer?

Yes
No

Employer name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Dates of employment

Position

Salary

Reason for leaving

Employer name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Dates of employment

Position

Salary

Reason for leaving

Employer name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Dates of employment

Position

Salary

Reason for leaving

REFERENCES

Name

First Last

Phone

Name

First Last

Phone

Name

First Last

Phone

PROFESSIONAL LICENSES, CERTIFICATIONS/REGISTRATIONS

Type

State issued

Type

State issued

Type

State issued

OTHER

Please list any other equipment/office machines you can operate

Please list any other job related skills possessed

Typing speed (WPM)

Affidavit: I certify that the answers given by me to the foregoing questions and statements are true and correct without consequential omissions of any kind whatsoever, I agree that my employer shall not be liable in any respect if my employment is terminated because of the falsity of statements, answers or employment, together with any information they may have regarding me whether or not it is in their records. I hereby release said employees, companies, schools or persons from all liability for any damage, both legal and otherwise, for issuing this information. I also understand a conditional offer of employment may be based on the passing of a pre-employment physical, drug screen and the background check Macon Community Hospital will perform. In addition, I hereby agree to abide by the rules and policies of Macon Community Hospital

Further, I understand that any employment is not for a stated period of time and may be terminated with or without cause, at any time, at the option of either myself or my employer.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

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Online Employment Application

Application for Employment

Macon County General HospitalWorking for Your Better Health

Please Read Carefully - Answer All Questions

EDUCATION INFORMATION

PAST/CURRENT EMPLOYMENT INFORMATION

REFERENCES

PROFESSIONAL LICENSES, CERTIFICATIONS/REGISTRATIONS

OTHER

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

Macon County General Hospital
Working for Your Better Health