APPLICATION FOR EMPLOYMENT

Position Applying For
Department
Date Applied
Last name
First name
Middle name

Present Address

Street and No.
City/State Zip

How long have you lived there?

Years
Months

Previous Address

Street and No.
City/State Zip

How long have you lived there?

Years
Months
Telephone No.

Are you 18 years of age or older?
Yes
No

Have you ever worked for this company before?
Yes
No

If yes, please give dates and position:

Dates
Position

Do you have any friends or relatives working here?
Yes
No

If yes:

Name
Relationship

Have you ever pled guilty or “no contest” to a crime, been convicted of a crime, had adjudication withheld, prosecution deferred or do you have any criminal charges pending?
Yes
No

If yes, please give date and details of each:

Previous Employment

Please list the names of your present or previous employers in chronological order with present or last employer listed first. Be sure to account for all periods of time including any period of unemployment.


Present or Past Employer

Address

City/State/Zip

Telephone

From

To

Pay

Position

Supervisor

Reason for leaving


Present or Past Employer

Address

City/State/Zip

Telephone

From

To

Pay

Position

Supervisor

Reason for leaving


Present or Past Employer

Address

City/State/Zip

Telephone

From

To

Pay

Position

Supervisor

Reason for leaving


Have you ever been terminated?
Yes
No

If yes, please explain circumstances:

Please explain fully any gaps in your employment history:

Education

School Name/Location

Years Completed

Degree

Study or Major

Elementary

High School

College/University

Graduate/Professional

Trade/Correspondence

Other

Personal References (No relatives)

Name

Relationship

Address

Telephone Number

This application will be considered active for a maximum of thirty (30) days. If you wish to be considered for employment after that time, you must reapply.

This company is an equal opportunity employer and does not discriminate because of race, color, religion, sex, age, citizenship, martial status, disability, or national origin.

EQUAL OPPORTUNITY EMPLOYER
APPLICANT’S STATEMENT

I understand that if I am hired, my employment will be for no definite period, regardless of the period of payment of my wages. I further understand that I have the right to terminate my employment at will at any time with or without notice or reason, and Madison County Memorial Hospital has the same right. No one other than the Chief Executive Officer/Administrator has authority to modify this relationship or make any agreement to the contrary. Any such modification or agreement must be in writing.

I understand that Madison County Memorial Hospital reserves the right to require me to submit to a drug test at any time and also reserves the right to require me to submit to an alcohol test and/or medical examination to the extent permitted by law. I further understand that Madison County Memorial Hospital may contact my previous employers and I authorize those employers to disclose to Madison County Memorial Hospital all records and other information pertinent to my employment with them. I release my previous employers from any liability as a result of their disclosure of information about me to Madison County Memorial Hospital. I also authorize Madison County Memorial Hospital to provide truthful information concerning my employment with it to my future prospective employers and I agree to hold it harmless for providing such information.

I further understand that if employed I will be on a 6 month probationary period, and that termination for unsatisfactory performance during that period will not result in any Madison County Memorial Hospital responsibility for unemployment benefits. I further understand that completion of the probationary period does not confer any expectation of continued employment, and that if employed, my employment will be for no definite period and “at-will.”

By signing this application, I certify that all of the information that I provide on this application and in any interview will be true, complete and accurate. I understand that if I am employed and any such information is later found to be false or misleading in any respect, I will be dismissed.

I certify that I have received a written notification that Madison County Memorial Hospital may obtain a consumer report or reports on me. I authorize this Hospital to obtain such a report or reports for use in connection with my application for employment and for other employment-related reasons. If hired, this authorization shall remain on file and serve as ongoing authorization for procurement of employment-related consumer reports at any time during my employment. I understand that the term “consumer report” includes, but is not limited to, credit checks, criminal background checks, Department of Motor Vehicle reports, and investigative consumer reports. I further understand that the term “investigative consumer report” means a report in which information on my character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with my neighbors, friends, or associates, or with others with whom I am acquainted or who may have knowledge concerning any such items of information.

Madison County Memorial Hospital
309 North East Marion Street · Madison, Florida 32340
(850) 973-2271 · Fax (850) 973-8158

PRE-EMPLOYMENT DRUG TESTING POLICY

All job applicants of Madison County Memorial Hospital (MCMH) will undergo screening for the presence of illegal drugs as a condition for employment. Applicants will be required to voluntarily submit to a urinalysis test at a laboratory chosen by MCMH, and by signing the consent agreement below, will release MCMH from liability. (Any applicant with positive test results will be denied employment at that time.) MCMH will not discriminate against applicants for employment because of past abuse of drugs or alcohol. It is the current abuse of drugs or alcohol, which prevents employees from properly performing their jobs that MCMH will not tolerate.

PRE-EMPLOYMENT AGREEMENT

PLEASE READ CAREFULLY

I freely and voluntarily agree to submit to a urinalysis (drug screen) as part of my application for employment. I understand that either refusal to submit to the urinalysis screen or failure to qualify according to the minimum standards established by MCMH for this screen might disqualify me from further consideration for employment. I further understand that upon commencement of employment with MCMH, I may again be required to submit to a urinalysis screen. I understand that refusal to take a requested urinalysis screen or failure to meet the minimum standards set for the screen may result in immediate suspension or discharge.

In the event that employment commences prior to the employer receiving the drug test results, I understand that I will be immediately discharged if the result comes back positive.

I have read in full and understand the above statements and conditions of employment.

Please type "I agree" to agree to the above terms: