Habersham County Medical Center
Application Form
PERSONAL INFORMATION
Name (last):
Name (first, middle):
Mailing Address:
911 address:
City: State: Zip:
Home phone: Business phone:
Email address:
Best hours to call:
List any relatives currently employed at HCMC:
(HCMC requires proof of identity and eligibility to work in the US upon employment.)
POSITION YOU ARE APPLYING FOR
Title: Salary requirement:
Referred by: Date you can start:
How did you learn about this opening?
EDUCATION RECORD
High school (name, city, state):
Business or technical school:
 Degree earned:
Undergraduate college (name, city, state):
 Degree earned:
Graduate school (name, city, state):
 Degree earned:
PROFESSIONAL LICENSES AND/OR CERTIFICATION
Type: Organization or State Issued:
Date Issued: Number:
Type: Organization or State Issued:
Date Issued: Number:
Type: Organization or State Issued:
Date Issued: Number:
MILITARY RECORD
Military Branch: Entry Rank: Separation Rank:
Occupational Specialty: Separation Date(s):
Specialized Training:
List Service Awards, Commendations:
WORK HISTORY (give info about your last 3 jobs, starting with the most recent)
Employer: Dates employed:
Address:
City: State: Zip:
Telephone: Ending salary:
Last manager's name and title:
Position Title:
Duties:
Reason for leaving: May we contact for reference?
Employer: Dates employed:
Address:
City: State: Zip:
Telephone: Ending salary:
Last manager's name and title:
Position Title:
Duties:
Reason for leaving: May we contact for reference?
Employer: Dates employed:
Address:
City: State: Zip:
Telephone: Ending salary:
Last manager's name and title:
Position Title:
Duties:
Reason for leaving: May we contact for reference?
 
Have you ever been convicted of a crime?
If so, what, when and where?
(Conviction of a criminal offense will not necessarily preclude your employment.)
Can you perform the essential functions of the position, with or without reasonable accomodation?
Use this space to give us further information which may assist us in placing you.
BUSINESS REFERENCES
(if applying for your first job, you may give academic and/or persoanl references
Name & Relationship Title Company Name & Address Telephone
AVAILABILTY INFORMATION
Primary position desired:
Will you accept another position: If so, what position?
Are you available to work:
 Weekends:    /    Holidays:
Rotating shifts: /    On Call:
I understand that emergency conditions may require me to temporarily work shifts other than the one for which I am applying and agree to such scheduling change as directed by my department head or administrator of this institution. I also understand that as my availability status changes, it is my responsibility to notify my department manger or the Human Resources Department. Such changes will be effective then, for any future employment.
PLEASE READ
This institution does not discriminate in hiring or any other decision on the basis of race, color, religion, sex, citizenship, national origin, ancestry, Vietnam era status, or on the basis of age or physical or mental disability. No question on this application is intended to secure information to be used for such discrimination.

I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from liability or responsibility all persons, companies or corporation supplying such information. I consent to take the physical examination, and such future physical examinations as may be required by this institution as such times and places as the institution shall designate. I understand that an offer of employment may be contingent on passing a drug screening and the physical examination which relates to the essential duties I would be required to perform.

I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.

If employed, I will be required to complete an Employment Verification Form (I-9), and within three days show satisfactory evidence of identity and eligibility for employment.

I certify that the statements and responses made in this application are true and correct. I agree that if the information given is found to be false or misleading in any way, it shall result in the denial of employment or termination of employment.

By submitting this application, I certify that I have read the foregoing carefully.