Secure Application for Employment
HR7940 Rev 07/02
Human Resources Department
1201 Seventh Street SE
Decatur, Alabama 35601
It is the policy of this facility to provide equal opportunity to persons regardless of race, religion,
age, gender, disability or any other classification in accordance with federal, state and local        
statutes, regulations and ordinances.                                                                                       
http://www.decaturmorganhospital.org
email:  jobs.dg@dmhnet.org
Date
This application will be active for 6 months.
Last Name                                    First Name                                  Middle Initial
   
Are You At Least 18 Years Old?

Last 4-digits of
Social Security Number


Home Phone And Cell Phone

Present Address

Present City

Present State

Present Zip Code

E-Mail Address

Current Open Position(s) for Which You Are Applying



Type of Position
Full Time
PRN
Part Time
Temporary
Shift

Weekend
Day
Night
Evening
Flex
Salary Requirement
$
Do you have adequate means of transportation to get to work on time each day?
If overtime work is required periodically, does this pose a problem for you?
Date Available For Work

Are You Legally Authorized to Work in the U.S.?
Have you ever been employed by Decatur Morgan, Decatur General, or Parkway Medical?
If yes, please give dates, department and supervisor: Are you related to another hospital employee?
How did you learn about this position?
State Employment
         Commission

Internet
Agency
Ad
Job Listing
School
Current Employee
Job Line
Other:


Have you ever been convicted of a felony or misdemeanor?
If yes, please describe in full.


Are you presently charged with any violation of the law?
If yes, give date, place and nature of each such event:

Are you currently excluded from participation in any federally funded healthcare program - including Medicare and Medicaid?
Are you aware of any potential exclusion from a federally funded health program?
Educational History
Type of School
Name of School

City, State
Check Last Year
Attended in School

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

School:
    City:
   State:
Dates attended:
to
1    2     3    4
Graduated?
Degree:
Other
School:
    City:
   State:
Dates attended:
to
1    2    3    4
Graduated?
Degree:
Other
School:
    City:
   State:
Dates attended:
to
1    2    3    4
Graduated?
Degree:
List any professional licenses, registration or certification you possess
(Include only the last 4 digits of your Driver's License, if applicable)
Include Type, State Issued, Expiration Date and Number.
Indicate if any licenses have been revoked, suspended or placed on probation.
Also indicate if you are ineligible to become licensed or certified in your field. Please explain.

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 
Emergency Contact
Name Address Phone Number Relationship