Putnam General Hospital

An Equal Opportunity Employer/Drug Free Workplace

Secure Application for Employment
HR7940 Rev 07/02
Human Resources Department
101 Lake Oconee Parkway
Eatonton, Georgia 31024
Putnam General Hospital recruits, hires, trains, assigns, promotes and compensates employees without regard to race, color, religion, sex, age, national origin marital status, sexual orientation or disability. No question on this application is intended to secure information to be used for such discrimination. Please be advised that all applicants considered for employment must undergo a drug screen and criminal record check prior to beginning employment.

http://www.putnamgeneral.com
email:  hr@putnamgeneral.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

Cell Phone
Mailing Address

 Mailing City

 Mailing State

 Mailing Zip Code

E-Mail Address
Previous Address

 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
 Temporary
Shift

 Weekend
Day
 Night
Evening
 Rotation
Salary Requirement
$
 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 for Putnam General Hospital?
If yes, when? Please list all relatives working for PGH.
How did you learn about this position?
putnamgeneral.com
 Other website (please list):
Eatonton Messenger
 Union Recorder
Other Newspaper (please list):
School
Current Employee
 Walk-In
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:
Arrests or charges that have been expunged need not be disclosed.
If yes, give date, place and nature of each such conviction.

Felony Conviction will not necessarily bar you from employment, but will be taken into consideration in relation to the desired job.
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
(DO NOT 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              Medical Terminology              Certified Coder
Proficient in Software: 
Business machines and/or equipment you can operate:
      
Other 

 


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