Application for Employment

An Equal Opportunity Employer

The following application allows you to apply for an advertised position without obtaining a paper application from CRMC. After completing the application, you will submit your information to CRMC electronically. If you have a resume in ASCII Text, HTML, MS Word, Adobe PDF or Postscript format, you may submit the file along with the application.

Before filling out this application, be sure to read our Standards of Performance.

Please answer all questions. If you have any trouble with this application, please contact our Human Resources department at 229-890-3533.

Personal Data
Last Name:
First Name:
Middle Initial:
SS#:
Street:
City:
State:
Zip:
Phone:
Phone number other than home where you can be reached:
Position applying for:
Date available for work:
Schedule:	Full TimePart Time
Shift:	1st2nd3rdWeekend
Have you worked at CRMC before?	YesNo
When?
If previously employed under a different name, please indicate that name:
Do you have relatives employed by CRMC?	YesNo
If yes, please indicate name and relationship:
In case of emergency, please notify:
Relationship:
Address:
Telephone:
Have you ever been convicted of a violation of any federal, state, county or municipal law, other than minor traffic violations? YesNo
If so, explain:
Educational Background - High School
Highest grade completed:	n/a9101112
Name of school:
Address of school:
Course of study:
Educational Background - College
Highest grade completed:	n/a1234
Name of school:
Address of school:
Course of study:
Degree Received:
Date Completed / Graduated:
Educational Background - Graduate School
Highest grade completed:	n/a1234
Name of school:
Address of school:
Course of study:
Degree Received:
Date Completed / Graduated:
Educational Background - Other / Trade School
Highest grade completed:	n/a1234
Name of school:
Address of school:
Course of study:
Degree Received:
Date Completed / Graduated:
Please list any additional courses, workshops, or seminars that relate to the position you are applying for:
Are you currently enrolled in school?	YesNo
Where?
Course of study:
Expected date of graduation:
Fields of work for which you are licensed, registered, or certified:
Professional license number:
Issued:
Expires:
Renewal:
U.S. Military Service
Branch:
Last rank:
Date entered:
Date discharged:
Employment Record - Begin with most recent employer. Include prior employment with CRMC. Employment dates must be included for application to be considered.
Employer #1
Employer:
Job Title:
Address:
Job Responsibilities:
Phone Number:
Date Began:
Date Left:
May we contact?	YesNo
Immediate Supervisor:
Ending Rate of Pay:
Reason for Leaving:
Employer #2
Employer:
Job Title:
Address:
Job Responsibilities:
Phone Number:
Date Began:
Date Left:
May we contact?	YesNo
Immediate Supervisor:
Ending Rate of Pay:
Reason for Leaving:
Employer #3
Employer:
Job Title:
Address:
Job Responsibilities:
Phone Number:
Date Began:
Date Left:
May we contact?	YesNo
Immediate Supervisor:
Ending Rate of Pay:
Reason for Leaving:
Employer #4
Employer:
Job Title:
Address:
Job Responsibilities:
Phone Number:
Date Began:
Date Left:
May we contact?	YesNo
Immediate Supervisor:
Ending Rate of Pay:
Reason for Leaving:
Employer #5
Employer:
Job Title:
Address:
Job Responsibilities:
Phone Number:
Date Began:
Date Left:
May we contact?	YesNo
Immediate Supervisor:
Ending Rate of Pay:
Reason for Leaving:
General Information Please describe your personal qualifications relative to the position for which you have made application. List any skills or abilities you wish considered. Include skills with equipment or machines you operate, computer skills, knowledge of special techniques or procedures, typing speed, etc. Please indicate wage expected.
References Please list three personal references. Please include address and telephone. Do not list relatives nor anyone living in your household.
How did you hear about Colquitt Regional Medical Center's available positions? Walk-in Newspaper Billboard Radio Television Internet Dept. of Labor Other (please list)

If you would like to upload an electronic copy of your resume, specify the local file name in the field below. We will accept the following formats: ASCII Text, HTML, MS Word, Adobe PDF, Postscript.

Please read and accept the following before submitting your application:

Applicant's Statement

Verification: I hereby certify that all answers given on this application (including supplements) are true and complete to the best of my knowledge. I understand that any misrepresentation or omission of facts given in my application and/or interviews may be sufficient cause for dismissal when discovered.
Application: I understand that completion of this application by me does not indicate there are any positions available and does not in any way obligate CRMC.
Authorization and Release: I authorize CRMC to make inquiries into all statements made by me and to obtain any information, transcripts, records, or documents pertaining to my background including but not limited to my personal, employment, and financial history and other related matters. I authorize all schools, individuals, and employers to respond to inquiries in connection with my application. I hereby release all parties, including CRMC, from any and all liability or damages arising therefrom.
Employment-At-Will: I understand that this Employment Application and any other CRMC documents are not promises or contracts of employment. Should I be employed, I understand that my employment will not be for any particular period of time and will be at will. I can therefore terminate my employment with or without cause and with or without notice at any time and CRMC has a similar right. I understand that no manager or representative of CRMC has any authority to enter into any agreement for employment for any specified period of time or make any agreement contrary to the foregoing, except that the Hospital Administrator may do so in writing.
Physical Examination and Health Statement: I understand that I may be required to complete a health statement and submit to a preemployment physical after an offer of employment has been made. I release CRMC from any and all liability incident to the examination.
Alcohol and Drug Testing: I agree to submit to a urinalysis and/or blood test for the presence of drugs or alcohol and understand that my offer of employment will be contingent upon the results of these tests. I agree to such an examination and/or testing at CRMC's expense. I authorize release of the results to CRMC and release CRMC from any and all liability incident to the testing.
CRMC Policies: If this application is considered favorably, I agree to abide and comply with all rules- and policies of CRMC. I understand that if I do not do so, I may be subject to disciplinary action, up to and including discharge.
Standards of Performance: I have read and understand the Standards of Performance, I agree to comply with and practice the standards as outlined. (Standards of Performance are found on our web colquittregional.com.)

This application for employment shall be considered active for 30 days. Any applicant wishing to be considered for employment beyond this period should inquire as to whether or not applications are being accepted at that time.

By submitting this application, I am agreeing to the above terms.