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September 07, 2010

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SMC SOUTHSIDE MEDICAL CENTER, INC.

1046 Ridge Avenue, S.W., Atlanta, Georgia 30315 ph: 404.688.1350 fx: 404.688.2962 www.southsidemedical.net

APPLICATION FOR EMPLOYMENT


DATE: 09-07-2010
Southside Medical Center, Inc. does not discriminate in hiring on the basis of race, color, religion, sexual orientation, age, national origin, disability, or status in any other protected group.

Last Name:
First Name:
Middle Name:
Address:
Apartment:
Telephone Office:
Telephone Home:
City:
State:
Zip Code:
Position Desired:
Check type of employment desired:
Willing to work overtime ?
Are you:
Over the age of 18?
A previous applicant?
A previous employee?
Legally able to work in the United States?
A licensed driver with a car available for work?
Other than traffic violations, have you ever been convicted of a crime?
If yes, describe in detail:
Were you a member of a military branch?
If yes, provide: Branch
Rank
Indicate any foreign languages you can speak, read and/or write
FLUENT GOOD FAIR
  SPEAK
  READ
  WRITE
WORK HISTORY
Beginning with most recent employer, list all previous employment
Company Name:
Address:
Complement:
City:
State:
Zip Code:
Type of Business:
Job Title:
Dates of Employment:
Supervisor's Name:
Reasons for Leaving
Breifly Describe Your Duties
Company Name:
Address:
Complement:
City:
State:
Zip Code:
Type of Business:
Job Title:
Dates of Employment:
Supervisor's Name:
Reasons for Leaving
Breifly Describe Your Duties
Company Name:
Address:
Complement:
City:
State:
Zip Code:
Type of Business:
Job Title:
Dates of Employment:
Supervisor's Name:
Reasons for Leaving
Breifly Describe Your Duties
EDUCATION AND TRAINING
HIGH OR TRADE SCHOOL
Name and Location Of School:
Dates Attended:
Name and Date Of Degree Earned:
Diploma:
Major and Minor Fields of Study:
BUSINESS OR TECHNOLOGY SCHOOL
Name and Location Of School:
Dates Attended:
Name and Date Of Degree Earned:
Diploma:
Major and Minor Fields of Study:
OTHER TRAINING
Name and Location Of School:
Dates Attended:
Name and Date Of Degree Earned:
Diploma:
Major and Minor Fields of Study:
PROFESSIONAL INFORMATION (If applicable)
Professional Licensure:
License No:
Effective Date:
Expiration Date:

Registry or Certification:
Registration No:
Effective Date:
Expiration Date:

Out-of-State Licenses:
License No:
Is State Registration Pending?


SPECIALIZED SKILLS (including vocational training which may be job-related)

LIST MEMBERSHIPS IN ANY PROFESSIONAL OR CIVIC ORGANIZATIONS OR TRADE GROUPS

State any additional information you feel may be helpful to us in considering your application
REFERENCES
Do not list relatives or former employers
 NAME  MAILING ADDRESS  OCCUPATION YEARS KNOW

READ THE FOLLOWING STATEMENT CAREFULLY



I have answered all questions to the best of my ability. If employed, I realize that false information will be grounds for my dismissal. I hereby authorize any necessary inquiries as to my character, reputation, and ability and release those supplying any information from all liability. I understand that upon an offer of employment, I may be required to take a physical examination showing I am able to perform the duties of the job. I further understand that any job offered to me will be “at will” and not for any stated period of time.


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