RN - Clinical Informatics Specialist

1050 Valdosta Highway / Homerville, GA 31634 (Use the "Apply for this Job" box below)..org

APPLICATION FOR EMPLOYMENT Date: _______________________________ This institution is an equal opportunity provider and employer. DFWP

Last Name First Name Middle Name Maiden Name Current Address Number and Street City State Zip Code Social Security Number(Last four digits) XXX-XX
- Previous Address Number and Street City State Zip Code Telephone Number Are you at least 18? Yes No Position Desired Desired Salary Full Time Part Time Temp Willing to work? Evening Yes No Night Yes No Weekends Yes No Email Address Are you able to perform the essential, job related functions of the position for which you are applying with or without reasonable accommodations?

Yes No 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? Yes No

Name and Address of High School Dates Attended Graduate? Date Name and Address of College Course or Major Dates Attended Graduate? Degree Name and Address of Other Course or Major Dates Attended Graduate? Degree or Diploma

Name and Address Telephone Number Email Address Name and Address Telephone Number Email Address Name and Address Telephone Number Email Address

Begin with your most recent job. Employer’s Name May We Contact? Yes No Later Dates of Employment:
From:
To:
Employer’s Address Telephone# Supervisor’s Name:
Title Duties Reason for Leaving Email address Starting Salary Ending Salary

Employer’s Name May We Contact? Yes No Later Dates of Employment:
From:
To:
Employer’s Address Telephone# Supervisor’s Name:
Title Duties Reason for Leaving Email address Starting Salary Ending Salary

Employer’s Name May We Contact? Yes No Later Dates of Employment:
From:
To:
Employer’s Address Telephone# Supervisor’s Name:
Title Duties Reason for Leaving Email address Starting Salary Ending Salary

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List Number and Expiration Date of any Professional Occupational license State Driver’s License #(Last four digits) Are You Computer Literate? What Software? Typing speed? Office Equipment? Have you ever worked for Clinch Memorial Hospital before? Yes No If yes, give dates:
From ________To_______

I hereby state that the information given by me in the application is complete and true in all respects. I understand that any omission, misrepresentation, or falsification will preclude my application from further consideration. I further understand that if employed, the subsequent disclosure of any omission, misrepresentation, or falsification of information result in the may termination of my employment. If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without prior notice, except as may be required by law.

This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreement contrary to the foregoing express language are valid unl are in writing and signed by the employer’s administrator.

ess they I also understand that if I am hire , I will be required to provide proof of identity and legal authorization to work in the United d States and that federal immigration laws require me to complete an I-9 Form in this regard. I understand that reasonable safeguards will be taken to protect all personal information provided or obtained in conjunction with this application for employment.

My personal information may be shared with the employer’s affiliate(s) and third parties engaged by the employer to perform services for the employer. Any person information shared with an affiliate or third party is al to be used solely to perform the services requested by the employer. I understand that Clinch Memorial…