Secure Application for Employment
HR7940 Rev 07/02
Human Resources Department
1100 East Poplar St.
Clarksville, AR 72830
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.jrmc.com
email:  humanresources@jrmc.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?

Social Security Number (secure)

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
Full Time
PRN/Casual
Part Time
Temporary
Shift
Extended (12-16 hrs.)
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 during normal working hours?
Are you a smoker?
Date Available For Work

Are You Legally Authorized to Work in the U.S.?
Have you ever worked in this or any other facility?
If yes, what facility? Are you related to another facility employee?
If yes, who?

How did you learn about this position?
State Employment
       Commission

Internet
Agency
Ad (Newspaper)
Job Listing
School
Current Employee
Trade Magazine
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 (or Province):
Country:
9   10   11   12
Graduated/GED?
Degree:
College
School:
    City:
State (or Province):
Country:
1     2     3    4
Graduated?
Degree:
College
School:
    City:
State (or Province):
Country:
1    2    3     4
Graduated?
Degree:
Graduate
School

School:
    City:
State (or Province):
Country:
1    2     3    4
Graduated?
Degree:
Other
School:
    City:
State (or Province):
1    2    3    4
Graduated?
Degree:
Other
School:
    City:
State (or Province):
1    2    3    4
Graduated?
Degree:
List any professional licenses, registration or certification you possess
(Include 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 
Nursing Skills:

Insurance/Billing:

Management/Supervision:

Foreign Languages: