Clinical Lab Technologist: Precision Diagnostics

Overview

Clinch Memorial Hospital is an equal opportunity employer. This institution is an equal opportunity provider and employer.

APPLICATION FOR EMPLOYMENT

Date: _______________________________

• 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?
• 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
• Dates of Employment:
  From To
• Employer’s Address
• Telephone#
• Supervisor’s Name
• Title
• Duties
• Reason for Leaving
• Email address
• Starting Salary
• Ending Salary

Additional employment entries may be included as needed.

• 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 may result in 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 cause and 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 unless they are in writing and signed by the employer’s administrator.
• I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United 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 also to be used solely to perform the services requested by the employer.
• I understand that Clinch Memorial Hospital reserves the right to require its applicants to submit to a drug test. Refusal to submit to a drug test or a positive test result may preclude my application from further consideration. Clinch Memorial Hospital reserves the right to require its employees to submit to blood tests or urinalysis for alcohol or drugs, or to allow inspection of bags or parcels brought into or taken out of Clinch Memorial Hospital.
  
  A positive test result…