 |
North Alabama Medical Center
North Alabama Outpatient Services
North Alabama Shoals Hospital |
An
equal opportunity employer. |
 |
|
|
|
Application
date:
|
01/25/2021
|
 |
|
|
|
 |
Last
Name: required
|
First
Name: required
|
Middle
Name:
|
Specific Position(s) Desired: required
Facility:
[NAMC
]
[Shoals
] required |
Current
Address (Number and Street): required
|
|
Select:
[Full Time
] [ Part Time
] [ Temp
] [PRN
] |
City: required
|
State: required
|
Zip
Code: required
|
Willing
to work weekends?
Willing to work holidays?
Willing to work shifts?
|
Yes
Yes
Yes |
No
No
No |
Telephone: required
(
)
|
Social
Security Number: required
|
|
Days
Nights
Evenings |
Yes
Yes
Yes |
No
No
No |
|
Are you at least 18 years of age? |
Yes
No |
 |
Referral
Source:
Advertisement
Employment Agency
Walk In
Relative
Friend
Other
|
|
Are
you currently a member of a reserve unit? |
Yes
No |
Professional
organizations, interests, hobbies (omit any which might indicate race,
religion, color, national origin, disability, age, sex or ancestry.)
|
 |
|
|
|
 |
Name
& Address of High School: required
|
Dates
Attended: required
|
Graduate?
Yes
No |
Diploma
or GED:
|
Name
& Address of College:
|
Course
or Major:
|
Dates
Attended:
|
Graduate?
Yes
No |
Degree:
|
Name
& Address of Business, Technical, or Professional School(s) Attended:
|
Course
or Major:
|
Dates
Attended:
|
Graduate?
Yes
No |
Degree
or Diploma:
|
Other
Special Training or Certificates: |
|
 |
|
|
|
 |
List
Number and Expiration Date of Any Professional or Occupational Licenses:
|
State:
|
|
List
any Maintenance or Shop Equipment you operate:
|
List
any Office Equipment
you Operate:
|
List
Computer
Software Skills:
|
|
|
Do
you type? |
Yes
No |
WPM:
|
|
|
Personal
/ Professional References:
Name:
Phone:
Name:
Phone:
|
In Case
of Emergency Notify
Name:
Address:
Phone:
|
 |
|
|
|
 |
Begin
with your most recent job. Use comments area below if necessary. |
|
|
Dates
of Employment:
From:
To:
|
Employer's
Name: required
Employer's Address: required
|
Supervisor's
Name: required
Supervisor's Phone: required
|
Reason for Leaving:
|
Starting Salary:
Ending Salary:
Job Title/Duties: required
May we contact?
Yes
No
Full Time
Part Time
PRN
|
Dates
of Employment:
From:
To:
|
Employer's
Name:
Employer's Address:
|
Supervisor's
Name:
Supervisor's Phone:
|
Reason for Leaving:
|
Starting Salary:
Ending Salary:
Job Title/Duties:
May we contact?
Yes
No
Full Time
Part Time
PRN
|
Dates
of Employment:
From:
To:
|
Employer's
Name:
Employer's Address:
|
Supervisor's
Name:
Supervisor's Phone:
|
Reason for Leaving:
|
Starting Salary:
Ending Salary:
Job Title/Duties:
May we contact?
Yes
No
Full Time
Part Time
PRN
|
Dates
of Employment:
From:
To:
|
Employer's
Name:
Employer's Address:
|
Supervisor's
Name:
Supervisor's Phone:
|
Reason for Leaving:
|
Starting Salary:
Ending Salary:
Job Title/Duties:
May we contact?
Yes
No
Full Time
Part Time
PRN
|
Have
you ever worked for any of the North Alabama Medical Center facilities?
Yes
No
|
If
yes, which facility?
|
Dates
From:
|
To:
|
Name
of Relatives Employed by any North Alabama Medical Center facility:
|
Relationship:
|
|
|
 |
|
|
|
 |
1.
Have you ever been convicted of any crime other than a minor traffic violation?
|
Yes
No |
|
If
yes, list offenses:
|
Date
of Conviction:
|
|
2.
Have you ever been refused a surety bond? |
Yes
No |
Why?
|
3.
Are you able to perform the functions of the job for which you have applied
with or without an accommodation? |
Yes
No |
4.
Have you ever been discharged from a non-military position? |
Yes
No |
|
NOTE:
An answer of yes to any of the above questions does not necessarily disqualify
you from employment with North Alabama Medical Center. All hiring decisions will
be based on job-related factors which are consistent with business necessity. |
5.
Are you a citizen or otherwise authorized to work in the U.S.? |
Yes
No |
|
|
Upload Resume (NOT required. PDF or Word format only.):
|
|
Comments/questions/additions
(NOT required):
|
CERTIFICATE
OF APPLICANT
ATTENTION:
Read the following statement carefully before sending this application.
I
hereby state that the information given by me in this application is
true in all respects. I 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 any time. I hereby authorize my former employers to
release information pertaining to my work record, my work habits, and
my work performance while in their employ. In making application for
employment, I understand that an investigative report may be made by
a consumer reporting agency to include information as to my character,
general reputation, personal characteristics, and mode of living, whichever
may be applicable. If such an investigative report is made, I understand
that I will receive notice that such a report has been requested and
that I will have the right to make a written request for a complete
and accurate disclosure of additional information concerning the nature
and scope of the investigation.
I
understand and agree that any employee handbook which I may receive
will not constitute an employment contract, but will merely be a gratuitous
statement of North Alabama Medical Center current policies.
I
understand and agree that if I am offered employment by North Alabama Medical Center my employment will be for no definite term and that either I,
or North Alabama Medical Center, will have the right to terminate the employment
relationship at any time, with or without cause, and with or without
notice. I also understand that this status can be altered by a written
contract of employment that is specific as to all material terms, and
is signed by me and the Chief Executive Officer of North Alabama Medical Center.
I also understand and agree that the duties of the position, including
shift and location, may be changed without notice any time during employment.
I
consent to taking a post employment physical examination/drug screen
and such future physical examinations/drug screens as may be required
by the organization.
|
Name:
|
Initials:
|
Date: required
|
|
Email
Address: required
|
|
|
NOTE:
Pressing "Send" will submit your application. Please check your
information, as you will not be able to correct mistakes after sending. |
|
Only
press "Send" once! |