Complete Name
Street
City/State/Zip
Tel/Message Phone
E-mail
Former or Maiden Name
Social Security #

Are you willing to take a complete post employment physical exam / drug test
at our expense upon a conditional offer of employment?    Yes No

Have you ever been convicted of a felony?    Yes No

If yes, give date, place and reason.  Note: A conviction will not necessarily bar you from employment.

Have you been excluded or sanctioned by any Federal Health Care Program?    Yes No

Have you been convicted of an offense that would preclude employment in a nursing facility?    Yes No

If yes, give date and explanation:

Are you either a citizen of the U.S. or an alien who has the legal right to work in the job for
which you are applying?    Yes No

If no, give visa classification:

Have you ever worked for GMH before?    Yes No

If yes, give employment date and position, reason for leaving:

Please list any relatives you may have that are employed by GMH:

Position(s) you are applying for:

SHIFT DESIRED  7-3 3-11 11-7

List Special Skills (typing, computer, software knowledge, PBX, cash register, etc):

State Highest year of education and list all schools attended, degrees, certificates:

List all licenses and expiration dates

List present or most recent job.  Include Company Name, Complete address and phone number and reason for leaving; job title, job duties, your supervisor name, dates of employment and hourly salary rate:

***********

List second most recent job.  Include Company Name, Complete address and phone number and reason for leaving; job title, job duties, your supervisor name, dates of employment and hourly salary rate:

***********

List third most recent job.  Include Company Name, Complete address and phone number and reason for leaving; job title, job duties, your supervisor name, dates of employment and hourly salary rate:

************

List fourth most recent job.  Include Company Name, Complete address and phone number and reason for leaving; job title, job duties, your supervisor name, dates of employment and hourly salary rate:

*************

List two personal references with complete contact information( include phone number and address),
as well as the individual's occupation:

List additional skills or qualifications:

 

AFFIDAVIT:  I understand that my application for employment will be active for 45 days from date of completion. I understand a conditional offer of employment may be made based upon results of a medical examination / drug screening. I certify that I have not been convicted of an offense that would preclude employment in a nursing facility and that I am not excluded from participation in any Federal health care programs.? I certify that I am not required to register under the provisions of the Oklahoma Sex Offenders Registration Act or the Mary Rippy Violent Crime Registration Act. I hereby certify that all of the above statements are true and I understand and agree that I am subject to immediate discharge without recourse if information provided is found to be untrue. I authorize all my past or present employers to furnish Grady Memorial Hospital all information they may have concerning me, and I hereby release them and Grady Memorial Hospital from all liability for any damage whatsoever arising there from, understanding the employment decision may be based in part upon the results of the investigation. I further authorize Grady Memorial Hospital to obtain a report containing information regarding my prior work related injuries, claims, and lawsuits, education verification, driving history and criminal history in connection with evaluating me for employment, promotion, reassignment or retention as an employee.? I understand that if I am employed, such employment is for no definite period of time. Grady Memorial Hospital can change wages, benefits, and conditions at any time. I also understand that the hours per week I am scheduled may vary according to patient census. I further understand that this is an application for employment and that no employment contract is being offered.

Entering your name and date below serves as an electronic signature and constitutes acceptance of the affidavit above.