Secure Application for Employment
HR7940 Rev 07/02
Human Resources Department
126 Hospital Avenue
Ozark, Alabama 36360
 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://dmc3al.fasthealth.com

 		Date
This application can be active as long as legally required.
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
Previous Address

 Previous City

 Previous State

 Previous Zip
Current Open Position(s) for Which You Are Applying



 Type of Position
Per Diem
 Pool
Full Time
 PRN
Part Time
 Temporary
Shift

Weekend
Day
 		Night
Evening
 Rotation
Salary Requirement
$
Are You Willing To Travel?

Are You Willing To Relocate?

Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?
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 worked in this facility?
If yes, what facility? Are you related to another facility employee?
How did you learn about this position?
State Employment
         Commission
 Internet
Agency
 Ad
Job Listing
 School
Current Employee
 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 convicted of a crime and/or released from confinement following a conviction for any criminal offense?
Arrests or charges that have been expunged need not be disclosed.
If yes, give date, place and nature of each such conviction.
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 - and 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:
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:
Other
 School:
    City:
   State:
1    2    3    4
Graduated? 		Degree:
Other
 School:
    City:
   State:
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