Chestatee Regional Hospital



Secure Application for Employment

Human Resources Department
227 Mountain Drive
Dahlonega, Georgia 30533
It is the policy of this facility to provide equal opportunity to all employees and applicants without regard to race, color, creed, religion, national origin, gender, age, disability, marital status, veteran status, sexual orientation, citizenship or any other characteristic protected by law in all employment decisions, including but not limited to recruitment, hiring, compensation, training, apprenticeship, promotion, upgrading, demotion, downgrading, transfer, lay-off, termination and all other terms and conditions of employment.

http://crh2ga.fasthealth.com

Date
This application will be active for twelve months.
Last Name                                    First Name                                  Middle Initial
   
Are you at least 18 years of age?

Did anyone refer you here for employment purposes?
If yes, who?
Date of Birth (Example: 10/23/1974)
Last 4-digits of
Social Security Number


Contact numbers:

Present Address

Present City

Present State

Present Zip Code

E-Mail Address

Previous Address (if less than 12 months)

Previous City

Previous State

Previous Zip

Current Open Position(s) for Which You Are Applying
Type in name of the desired position:  


Type of Position
Full Time
PRN
Part Time
Shift

Weekend
Day
Night
Evening
Rotation
Salary Requirement
$
Do you have adequate means of transportation to get to work on time each day and when called in on short notice?
Are you willing to work overtime when scheduled or requested?
Date Available For Work

Do you currently have unrestricted work authorization or are you legally allowed to accept employment in the United States?
Have you ever been employed here?
If yes, give position and dates worked. Are any of your relatives or persons you are involved in a close personal relationship with here currently?
If yes, list name and relationship:
How did you learn about this position?
State Employment Commission
Internet
Agency
Ad
Job Listing
School
Current Employee: If yes, who
Job Line
Other:

Are you able to perform the essential, job related functions of the position for which you are applying with or without reasonable accommodations?
Describe any accommodations necessary:

Have you been arrested or convicted of a crime or misdemeanor? 
Arrests or charges that have been expunged need not be disclosed.
If yes, give date, place and nature of each such conviction.

The existence of an arrest or conviction of a crime or misdemeanor will not necessarily be a bar to employment.
The nature and gravity of the offense, the time that has passed since the arrest and the nature of the job will be
taken into consideration.
Educational Background - Amount of education necessary will vary according to the job in which applied
Type of School
Name of School

City, State
Check Last Year
Attended in School

Degree or Certificate
High School
School:
    City:
   State:
9   10   11   12
Graduated/GED?
Degree:
College
School:
    City:
   State:
1     2     3    4
Graduated?
Degree:
College
School:
    City:
   State:
1    2    3     4
Graduated?
Degree:
Graduate
School

School:
    City:
   State:
1    2     3    4
Graduated?
Degree:
Technical or Business
School:
    City:
   State:
1    2    3    4
Graduated?
Degree:
Other
School:
    City:
   State:
1    2    3    4
Graduated?
Degree:
Professional Licenses and Certifications
Also, please indicate if any license has been revoked, suspended or placed on probation.

TypeStateDate IssuedNumber How many years
have you had this
credential/license total?
Clerical or other skills applicable to the position for which you are applying
Typing (WPM)              PBX
Proficient in Software: 
Business machines and/or equipment you can operate:
      
Other