NAMC Employment Application

		North Alabama Medical Center ECM East Shoals Hospital		An equal opportunity employer.

			Application date:	05/25/2020


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!