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* 1. This is an application for Employment with Calhoun Liberty Hospital, an Equal Opportunity Employer. We do not discriminate on the basis of race, color, religion, national origin, sex, age or disability. It is our intention that all qualified applicants are given equal opportunity, and that selection decisions be based on job related factors.
Answer each question fully and accurately.
No action can be taken on this application until you have answered ALL questions. In reading and answering the following questions, you are aware than none of the questions are intended to imply illegal preferences or discrimination based upon non-job related information. If you would like to proceed, please click proceed below.

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* 2. Today's Date

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* 3. Position Applying for

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* 4. If this is a professionally licensed position, please provide your license #

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* 5. Are there now, or have there ever been any sanctions against your license

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* 6. Type of Employment you are seeking

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* 7. Date Available to being work

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* 8. What is your contact information?

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* 9. Are you 18 years of age or older?

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* 10. If hired, can you submit proof of age?

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* 11. If hired can you submit proof of eligibility to work in the US?

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* 12. Have you ever applied to CLH before?

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* 13. Have you ever been employed by CLH before?

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* 14. Have you ever been arrested for any violation of the law, excluding minor traffic violations?

Please note a "yes" answer does not automatically disqualify you from employment since the nature of the offense; date and job you are applying for are also considered.

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* 15. Are you currently Employed?

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* 16. May we contact your current Employer?

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* 17. How many days of work have you missed during the past year?

0 365
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i We adjusted the number you entered based on the slider’s scale.

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* 18. FOR DRIVING JOBS ONLY:

Do you have a valid FL Driver's license?

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* 19. FOR DRIVING JOBS ONLY:

Do you have a valid FL Driver's License?

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* 20. FOR DRIVING JOBS ONLY:

Have you had your drivers license suspended or revoked in the last three (3) years? 

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* 21. Please list any professional, trade, business, or civic activities and office held. Exclude Labor organizations and memberships which reveal race, color, religion, national origin, sex, age, disability, or other protected status. 

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* 22. Education (Please list all that apply) include name of school or university, what years did you attend, and what certificate/diploma/degree you received. 

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* 23. What skills or additional training do you have that relate to the job you are applying for?

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* 24. What machinery and/or equipment can you operate that might be related to the job for which you are applying?

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* 25. Have you ever worked or attended school under another name?

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* 26. Contact information for your most recent employer?

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* 27. Contact information for your next most recent employer?

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* 28. Contact information for your third most recent employer?

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* 29. Please provide contact information for three (3) references. References can be personal or professional, but do not list relatives.

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* 30. Please provide contact information for three (3) references. References can be personal or professional, but do not list relatives.

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* 31. Please provide contact information for three (3) references. References can be personal or professional, but do not list relatives.

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* 32. PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING
I certify that all information provided in this employment application is true and complete. I understand that any false information or omissions may disqualify me from further consideration for employment and may result in my dismissal, if discovered at a later date. I understand that the employer may request an investigative consumer report from a consumer reporting and/or law enforcement agency. This report may include information as to my character, reputation, personal characteristics and mode of living obtained from interviews with neighbors, friends, former employers, schools and others. I understand that I have a right to make a written request within a reasonable time for the disclosure of the name and address of the consumer reporting agency, so that I may obtain a complete disclosure of the nature and scope of the investigation.

I authorize the investigation and all statements contained in this application. I also authorize whether listed or not, any person, school, currently employer, past employers and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I understand that if I am extended an offer of employment, it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any and all medical information as may be deemed necessary to judge my capability to do the work for which I am applying. I understand that I may be required to successfully pass a drug screening examination. I hereby, consent to a pre, post and/or random employment drug screen, as a condition of employment if required.
I understand that this application or subsequent employment, does not create a contract of employment, nor guarantee employment for any definite period of time. If employed, I understand that I have been hired at the will of the employer and my employment may be terminated at any time, with or without cause, and with or without notice.

By typing your name below, you are accepting the above declaration.

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