Smith Northview Hospital


Secure Application for Employment
HR7940 Rev 07/02
Human Resources Department
4280 North Valdosta Rd
Valdosta, GA 31602
229-671-2004
 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.smithhospital.com
email:  hr@smithhospital.com
 Date
This application can be active as long as legally required.
Last Name                                    First Name                                  Middle Initial
   
Home Phone

Cell Phone
Address

 City

 State

 Zip Code

E-Mail Address
Current Open Position(s) for Which You Are Applying



 Type of Position
Full Time
 PRN
Part Time
Shift

 Weekend
Day
 Night
Evening
 Rotation
Pay Requirement
$
Are You Currently Employed?

May we contact your present employer?

 Do you have adequate means of transportation?
Date Available For Work

Are You Legally Authorized to Work in the U.S.?
Have you ever been employed here before?
If yes, please list dates of employment. Are you related to another Smith Northview Hospital employee? If so, who?
How did you learn about this position?
State Employment
       Commission
 Internet
Agency
 Ad
Job Listing
 School
Job Line
  
Current Employee
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:
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,
University,
Vocational
 School:
    City:
   State:
1     2     3    4
Graduated?
Degree:
Describe course of study:
Graduate/
Professional
School
 School:
    City:
   State:
1    2     3    4
Graduated? 		Degree:
Other
 School:
    City:
   State:
1    2    3    4
Graduated? 		Degree:
Describe specialized training, apprenticeships, skills, and extra-curricular activities
List any professional licenses, registration or certification you possess
(CPR, ACLS, etc.)
Include Type, Expiration Date, License Number, and Years Held.
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)
Proficient in Software: 
Business machines and/or equipment you can operate:
      
Other