Title: General Application

Fields marked with an asterisk (*) must be filled out before submitting.

Personal Details

First Name *
Last Name *
Email Address *

Contact Details

Address
City
Post code
Country
Telephone
Cell phone

Qualifications

Do you have a degree? Yes
No
Where did you complete your degree?
Title of your degree
 
Position Desired
Date Available
Desired Schedule Fulltime
Weekends
Part Time/PRN
On Call
Other
Desired Location NORTH TEAM: Gilmer, Fannin & Union Counties
SOUTH TEAM: Cherokee, Pickens & Dawson Counties
NORTHWEST TEAM: Murray Whitfield & Gordon Counties
Any Location Needed
Float
Automobile Available Yes
No
Do you have a drivers license in good standing Yes
No

Education

High School Name
City/State
Did you graduate? Yes
No
Years Completed 1
2
3
4
GED Equivalent Yes
No
 
College Name
City/State
Years Completede 1
2
3
4
Did you graduate? Yes
No
Degree/Major
 
Other (specify)
City/State
Years Completed 1
2
3
4
Did you graduate? Yes
No
Course of Study

Skills

List any special qualifications or skills (including computer)

License/Certificate (RN, LPN, CNA, CPR, etc.)

Type & License Number
Issued by (state)

EMPLOYMENT – Current or Most Recent

Name of Employer
Address
City/State
Zipcode
Name of Supervisor
Length of Employment (Years/Months)
Job Title
From:
Average hours worked per week?
Salary
Hourly Wage
Reason for leaving
Description of Duties
To:

EMPLOYMENT – Next Most Recent

Name of Employer
Address
City/State
Zipcode
Name of Supervisor
Length of Employment (Years/Months)
Job Title
From:
To:
Average hours worked per week:
Salary
Hourly Wage
Reason for leaving
Description of Duties & Responsibilities

PLEASE ANSWER ALL QUESTIONS

Are you a citizen of the United States of America Yes
No
If not a citizen, what is your U.S. status?
From what Country are you a citizen?
What is your Resident Alien Number (if any)?
What is your U.S. Visa type?
Within the last five years, has your employment been involuntarily terminated for any reason? Yes
No
Within the last five years, have you quit a job after being notified your employment would be terminated? Yes
No
Within the last five years, have you been unemployed for any period of time? Yes
No
If you answered “yes” to any of the above questions, please provide detailed information in the area provided
Have you ever been convicted of an offense against the law or forfeited collateral, or are you now under charges for any offense against the law? Yes
No
If you answered yes, please provide detailed information (include dates, charges, places, dispositions)

PERSONAL REFERENCES – Must list 3 References

Name of Person #1
Business or Occupation
Address
City/State
Phone
 
Name of Person #2
Business or Occupation
Address
City/State
Phone
 
Name of Person #3
Business or Occupation
Address
City/State
Phone

Pre-Employment Statement

This Equal Opportunity Employer considers all applicants regardless of race, creed, color, religion, sex, national origin, or disability. Please read the statements below, if you agree with them, check the adjacent boxes.
* I certify that the information given by me in this application is true and correct without omissions of any kind. I authorize an inquiry to be made into the information contained in this application if I am considered for employment. I also agree to submit to a medical examination and a drug screening as a condition of employment, if requested.
* I authorize former employers and education institutions named herein to give information about me. I hereby release them from all liability for issuing such information. I hereby waive any privilege I have to such information.
* I understand that employment is subject to the policies and regulations of the agency, and submitting documentary proof of identity and legal authorization to work in the United States as required.
* I understand and acknowledge that if any misrepresentation or omission of material facts has been made by me, or if the results of an investigation is not satisfactory for any reason, consideration, offer, or actual employment by the agency may be terminated immediately without obligation or liability to me other than payment at the rate agreed upon for service actually rendered, if any.
* I understand that nothing contained in this employment application or in the granting of an interview, and no agency policies, procedures, or handbooks that I might receive are intended to create an employment contract between the agency and myself for either employment or for the providing of any benefit.

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