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Employment Application
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McGehee Hospital Application for Employment
Prospective employees will receive consideration without discrimination because of race, creed, color, sex, age, national origin, or disability. E.O.E
___________________________________________________________________________________
Today's Date:
*
Name
*
First
Last
Social Security No:
*
Driver’s License No:
*
Email
Phone
*
Business Phone
(If you can be contacted at current job)
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
___________________________________________________________________________________
Position Details
Position Applying For
*
Pay Expected
*
Have you ever applied for employment with us?
*
Yes
No
Are you legally eligible for employment in the United States?
*
Yes
No
Are you:
*
Under 18 yrs of age
Between 18-70 yrs of age
Over 70 years of age
When will you be available to begin work if a position is offered?
*
Type of Employment Desired :
*
Full-time
Part-time
School: Highest level of education
*
College
VoTech
High School
Other
Name And Location
Course
Degree
Year Graduated
Membership in professional or civic organizations (exclude those, which may disclose your race, color, religion, or national origin):
Please list other special training skills such as languages, equipment operated, typing, special medical courses, etc.
Do any of your friends or relatives work for McGehee Hospital?
*
Yes
No
Name and relationship if answered yes
If the offer of a position is extended to you, you will be required to pass a drug screen for illegal substances at our expense. Should you fail this drug screen, the offer of employment will be automatically withdrawn.
___________________________________________________________________________________
Employment History
Please give accurate, complete full-time and part-time employment history. Start with the present or most recent employers.
1. Company Name
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
Dates Employed
From/To
Name of Supervisor
First
Last
Pay
State job title and describe your work:
2. Company Name
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
Dates Employed
From/To
Name of Supervisor
First
Last
Pay
State job title and describe your work:
3. Company Name
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
Dates Employed
From/To
Name of Supervisor
First
Last
Pay
State job title and describe your work:
___________________________________________________________________________________
Please indicate those employers you do not wish us to contact and reasons why:
___________________________________________________________________________________
Military Service: Complete this section if you served in the United States Armed Forces.
Branch of service
Period of active duty:
From/To
Rank At Time Of Discharge:
Date of final discharge
Describe your duties and any special training:
___________________________________________________________________________________
The information requested is needed for a legally permissible reason including without limitation: National security consideration, a legitimate occupational qualification of business necessity, the Civil Rights Act of 1964 prohibits discrimination in employment because of race, color, religion, sex, or national origin. Federal law also prohibits discrimination on the basis of age with respect to certain individuals. Federal law as well as the laws of most states also prohibits some or all of the above types of discrimination as well as some additional types such as discrimination based on ancestry, marital status, or physical or mental handicap or disability.
Height
*
Weight
*
In (lbs.)
Gender
*
Male
Female
Marital Status
*
Single
Separated
Engaged
Divorced
Married
Widowed
Are you allergic to any food or medications?
*
Yes
No
If yes, what?
Have you been treated or tested for latex allergies or sensitivities?
*
Yes
No
If yes, explain:
Are you a United States citizen?
*
Yes
No
Please be able to provide us with proof of your legal right to employment in the country such as birth certificate, naturalization papers, immigration service permit or green card
What was your previous address?
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
How long were you at your previous address?
*
From/To
How long have you been at your current address?
*
From/To
Have you ever been bonded?
*
Yes
No
If yes, with which employer?
Have you ever been convicted of a crime in the past ten years, excluding misdemeanors and summary offenses, which have not been annulled, expunged, or sealed by a court?
*
Yes
No
Answering "YES" to these questions does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation, and position applied for will be taken into account. *
If yes, please describe in full:
Cover Letter, Resume, & References
Click or drag files to this area to upload.
You can upload up to 3 files.
___________________________________________________________________________________
I hereby declare the information provided by me in this application for employment is true, correct and complete to the best of my knowledge. I understand that, if employed, any misstatement or omission of act on this application shall be considered cause for dismissal. I authorize McGehee Hospital/Southeast Arkansas Home Health to obtain an investigative consumer report containing information through personal interviews with my neighbors, friends, and acquaintances. This report, if obtained, may include information as to my character, general reputation, personal characteristics and mode of living. I understand I have the right to make a written request within a reasonable period to receive additional detailed information about the nature and scope of any such investigation. I am qualified, with reasonable accommodation, to perform the specific and essential tasks of the position as outlined in the job description for this position.
Applicant Signature
*
Clear Signature
Submit
Home
About
Mission & Values
Message from the CEO
A Brief History
Board of Trustees
Community Health Needs Assessment
Share the Pride
Sustain the Pride
What to Expect
Services
Emergency Department
Clinical Laboratory
Radiology
Respiratory Therapy
Specialty Clinic
Hands On Rehab Services
McGehee Family Clinic
Nursing
Swing Bed
IDHI Stroke Program
Pharmacy
Chronic Care Management
Physicians
Careers
Benefits
Opportunities
Apply Now
Patients & Visitors
Admissions Information
Advance Directives
Bill Pay
Financial Assistance
Medical Records
Medicare Waiver/Advance Beneficiary Notice FAQ
Patient Portal
Price Transparency
Donate
Search
McGehee Hospital
900 South Third St.
McGehee, Arkansas 71654
T: (870) 222-5600