Hospital Employment Application Form

South Central Regional Medical Center, P.O. Box 607, Laurel, MS 39441

Thank you for your interest in employment at South Central Regional Medical Center. You must complete your own application. Incomplete applications will not be considered. Human Resources staff will be happy to assist you in completing your application should you need assistance. Falsification of information on this application is grounds for termination if you are hired. Your application will remain active for 90 days. If you have not heard from us by that time, you may submit a new application. South Central Regional Medical Center is an Equal Opportunity Employer.



Application for Employment
Position Applying For Todays Date Email
Last Name First Name M I
Address City State
Zip SSN
Telephone #1 Telephone #2
Are you 18 years of age or older? Yes No
Are you legally authorized to work in the United States? Yes No
Have you ever applied for work here before? Yes No If yes, date(s), position(s)
Have you ever worked at SCRMC or any affiliates? Yes No If yes, date(s)
Have you ever worked under another name? Yes No If yes, Name(s)
Have you ever been convicted, plead guilty or no contest to a felony or misdemeanor? Yes No If yes, explain:
(Note: State law requires that all individuals be fingerprinted and a criminal background conducted prior to beginning work.)
 
Have you ever been debarred, excluded, or determined ineligible for participation in Medicare or Medicaid programs? Yes No
Are you related to a member of the Hospital Board of Trustees? Yes No
Please list relatives working at SCRMC
Please list all friends working at SCRMC
Are you available to work overtime? Yes No
Are you available to work holidays? Yes No
If hired, will you be engaged in any other work, business or school? Yes No If yes, list hours/days
Please select shifts available to work Any Shift
Day Shift
Night Shift
Weekend Shift
Other
 
Please select days available to work Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
 
Please select preferred employment status Full Time
Part
PRN
Temporary
Other
 
Are there any days/hours you cannot work? Yes No If yes, please list
Are you a SCRMC scholarship recipient? Yes No
Have you ever been disciplined by an employer, involuntarily terminated(fired), or asked to resign from a position? Yes No If yes, please explain
 

Education Information

 
Highschool
Highschool Years Completed
Graduated? Yes No
 
College
College Years Completed
Major Graduated? Yes No
 
Graduate School
Graduate School Years Completed
Major Graduated? Yes No
 

Licensure / Certification / Special Training

 
Please list any special training you have received, or
any specialty areas for which you are currently certified/licensed.
Please include any state or national medical or healthcare related
license ( i.e. RN, LPN, LWS, CNA, etc.
 
License/Certification Number
Original Issue Date Years in this Profession
Expiration Date
License/Certification Number
Original Issue Date Years in this Profession
Expiration Date
License/Certification Number
Original Issue Date Years in this Profession
Expiration Date
 
Have you ever had a restriction or disciplinary on your healthcare related license? Yes No
 

Professional Membership

 
Please list any professional memberships that are pertinent
to the position for which you are applying. You may exclude any
memberships which would reveal sex, race, religion, national origin,
age, ancestry, handicap or other protected status.
 
 

Employment History

 
Account for all employment, include present job and periods of
unemployment. Please include any military experience or job-related
volunteerwork. Start with current or most recent employment.
 
Employer
Dates Employed Company / Address / Phone
Position / Job Duties Supervisor Name
Salary Reason for Leaving
Employer
Dates Employed Company / Address / Phone
Position / Job Duties Supervisor Name
Salary Reason for Leaving
Employer
Dates Employed Company / Address / Phone
Position / Job Duties Supervisor Name
Salary Reason for Leaving
Employer
Dates Employed Company / Address / Phone
Position / Job Duties Supervisor Name
Salary Reason for Leaving
Employer
Dates Employed Company / Address / Phone
Position / Job Duties Supervisor Name
Salary Reason for Leaving
 
Have you ever had any jobs that are not listed above? Yes No
May we contact your current employer? Yes No What salary do you require?
Are you physically and mentally able to perform the job for which you have applied? Yes No
If not, could you perform functions if a reasonable accommodation were made?* Yes No
*This hospital has a policy of nondiscrimination with respect to employment of individuals with disabilities.
Information as to any handicap or disability obtained as a result of the foregoing inquiries will be kept
confidential except as permitted or required by applicable law or regulation. Medical condition information
is obtained for the purpose of allowing voluntary action to over come the effects of conditions which might
result in limited employment of qualified handicapped individuals. Providing the information is voluntary,
and failure to do so will not result in adverse treatment.
 
 

References

 
Please list the names, professions and telephone numbers of three references who are not relatives.
(Preferably previous supervisors or instructors.)
 
Name Profession Telephone
Name Profession Telephone
Name Profession Telephone
 

In Case of Emergency Notify

 
Name / Address  Relationship Telephone
Name / Address  Relationship Telephone
 
Referral Source Career Line Advertisement Employee
 

Please Read Carefully

I certify that the answers given by me to the foregoing questions and statements are true and complete to the best of my knowledge and that I have withheld nothing that would, if disclosed, affect this application unfavorably. I authorize the companies, schools or persons named above to give any information regarding my employment, character and qualifications together with any information they may have regarding me, whether or not it is in their records. I hereby release said companies, schools or persons from all liability for any damaged for issuing this information. I understand that any falsification, misleading, incorrect, or omitted information will render this application void, and if employed, would be cause for termination.

I agree to submit myself upon request by the hospital for a drug screen or physical examination by a physician designed by the hospital, and to future physical or mental examination, random drug screening, or other examination the hospital may require at a later date as condition of continued employment. I understand that strict adherence to the hospitals Alcohol and Drug Abuse Policy will be required.

I further authorize the medical center to conduct a background check, including previous criminal convictions and previous employment. I understand that failure to list previous criminal convictions or employment above will void this application, and if employed, would be cause for termination.

If employed, I agree as a condition of continued employment to acquaint myself with, and to abide by all Rules, Regulations, and policies as established or amended by the hospital. However, I understand that my employment and compensation can be terminated with or without notice at any time at the option of the hospital or myself. Nothing in this application fo employment should be construed to constitute a contract of employment between the hospital and the applicant. I understand that the hospital may from time to time alter or amend it Rules, Regulations, policies and procedures when in the sole discretion of the administration of the hospital such changes are necessary. I further understand that in any given situation the current Rules, Regulations, policies and procedures in effect shall govern.

I authorize the hospital to release to future prospective employers any information regarding my employment with the hospital or the information set forth in this application or gained by the hospital from other companies, schools or persons named in this application to give information regarding my employment, character, qualifications, and information they may have regarding me, whether or not it in their records. I hereby release the hospital from all liability for any damage for issuing this information.

If I am employed, I further understand and agree that when my employment is terminated by retirement or otherwise, I must return all of my Employers property in my custody, including office keys, manuals, uniforms and identification card before I am entitled to final payment of any amounts due me on separation.

I agree that I will settle any and all previously unasserted claims, disputes or controversies arising out of or relating to my application or candidacy for employment, employment and or/secession of employment with South Central Regional Medical Center, exclusively by final and binding arbitration before a neutral Arbitrator. By way of example only, such claims include claims under federal, state and local statutory or common law, such as the The Age Discrimination in Employment Act, Title VII of the Civil Rights Act of 1964, as amended, including the Amendments of the Civil Rights Act of 1991, the Americans with Disabilities Act, the law of contract and the law of tort. South Central Regional Medical Center by this provision does not waive any defenses otherwise available as to any such claims.

Signature of Applicant Date
 

Additional Comments

 
 
This site is secured with a Comodo SSL certificate.