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126 Hospital Avenue
Ozark, AL 36360
334-774-2601

Application for Employment

Personal Information

  
Last Name:
First Name:
Middle Initial:
SSN (no spaces or dashes):
Street Address:
City:
State:
Zip:
Home Phone:
Contact Phone:
Can you provide proof, if hired, that you are eligible to work in the U.S.? Yes No
Position applying for:
If your application is considered favorably, on what day will you be available for work?
Shifts you can work: 1st: 7:00 A.M. - 3:00 P.M.
2nd: 3:00 P.M. - 11:00 P.M.
3rd: 11:00 P.M. - 7:00 A.M.
 
Would you accept part-time work? Yes No
Would you accept temporary work? Yes No
Were you previously employed by us?  
Yes No    If yes, when:
Do you have adequate means of transportation to get to work on time each day when called in on short notice? Yes No
Review the Job Description for the Position for which you are applying. Do you meet the qualifications and have the ability to perform the essential job functions of this job?
Yes No    If no, please explain:
List any relatives working for us:  
Name:  Relationship: 
Name:  Relationship: 
Name:  Relationship: 
Are you now or have you ever been sanctioned by or excluded from the Medicare and/or Medicaid system? Yes No
Have you been convicted of or plead guilty to any criminal felony offense within the past seven years? Yes No
Have you been released from confinement following a conviction for any criminal offense within the past seven years? Yes No
Are you presently charged with any felony violation of law? Yes No
If your response to any of the preceding two questions was "YES", give the date, place and nature of each such conviction or pending charge. (The existence of a conviction or pending charge will not necessarily preclude you from employment: the nature of the crime and its relationship to the position applied for, the degree of rehabilitation of the applicant and the time elapsed since the crime or release from confinement will all be considered.)
Have you ever been discharged from a job or forced or asked to resign?
Yes No    If no, please explain:
Have you ever received any type of discipline, either oral or written, for violation of a prior employer’s safety rules, policies or procedures?
Yes No    If no, please explain:
CERTIFICATION OF APPLICANT

I hereby certify that all information given by me in this application is true in all aspects. 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 any time. I further certify and agree to abide by and comply with all of the rules and policies of Dale Medical Center.

Upon signing I further agree/understand:

I understand that the Hospital reserves the right to require its employees to submit to blood tests, urinalysis or breathalyzer tests for alcohol or drugs, or to allow inspection of bags or parcels (including purses, briefcases and lunch boxes) brought into or taken out of the plant. I understand that refusal to submit to a breathalyzer test, urinalysis, blood test or search when requested to do so, may result in termination of my employment.

That any employee handbook which I may receive will not constitute an employment contract, but will be merely a gratuitous statement of the Hospital's current policies.

I understand and agree that if I am offered employment by the Hospital, my employment will be for no definite term and that either I, or the Hospital, will have the right to terminate the employment relationship at any time, with or without cause, and with or without notice and that this relationship can only be modified in writing and signed by the Administrator.

To work as scheduled (weekends/holidays, scheduled or unscheduled overtime).

To placement on other than initial work shift and/or work unit at the discretion of the employer.

That employment does not become effective until all personal data is verified and is acceptable to the employer and I have satisfactorily completed my initial period of employment and my pre-employment physical examination.

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. I release from liability all persons and former employers who furnish any information to Dale Medical Center in good faith and without malice.

In submitting this application for employment, I understand that an investigation may be made whereby information is obtained regarding my motor vehicle record, character, previous employment, general reputation, educational background, credit record and / or criminal history.
Full Legal Name of Applicant:
Date of Application:

Thank you for completing this application. You can be assured that our review of your job qualifications will be based solely on merit and a final determination reached as quickly as possible.

PLEASE CHECK TO SEE THAT YOU HAVE ANSWERED ALL THE ABOVE QUESTIONS
 
YOUR APPLICATION WILL BE CONSIDERED ACTIVE FOR 30 DAYS. FOR CONSIDERATION AFTER THAT TIME PERIOD YOU MUST REAPPLY.