Grady Memorial Hospital


Secure Application for Employment
HR7940 Rev 01/14
Human Resources Department
2220 West Iowa Avenue
Chickasha, Oklahoma 73018
It is the policy of Grady Memorial Hospital and it's entities 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.gradymem.org

Date
This application can be active as long as legally required.
Last Name                                    First Name                                  Middle Initial
   
Last 4-digits of
Social Security Number

Cell Phone Or Home Phone

Present Address

Present City

Present State

Present Zip Code

E-Mail Address

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


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

Weekend
Day
Night
Evening
Rotation
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 for Grady Memorial Hospital?
If yes, give employment dates, position and reason for leaving. Please list any relatives you may have employed at GMH.
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 ever been convicted of a felony?
NOTE: A conviction will not necessarily bar you from employment.
If yes, give date, place, and reason:

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 -AND- I certify that I am not required to register under the provisions of the Oklahoma Sex Offenders Registration Act or the Mary Rippy Violent Crime Registration Act?
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 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