Applicant NameLastFirstMIOther NamesApplication DateAddress Street/PO Box/Apt No.CityStateZip CodeTelephone-HomeCellWorkMessageSocial Security NumberPosition DesiredFirst ChoiceHospital Doesn’t MatterNursing Home Second ChoiceHospital Doesn’t MatterNursing Home Third ChoiceHospital Doesn’t MatterNursing Home Are you applying for: Full Time Part Time Part Time/Occasional/PRN Temporary Shift Availability: Day Shift Evening Shift Night Shift Other________ Salary Expected $_____Date you would be available to start work?_______________Professional Licensure/Certifications: (RN, LPN, C.N.A., CMA)Original State_____ License/Cert #)________________ Exp. Date_________ Addt’l State________ Lic#___Is your license restricted? ______If yes, what accommodations are necessary?__________________________EducationName & Location of SchoolDiplomas/Degrees, Rec’dSecondary School(High School)CollegeTrade SchoolGraduate SchoolWE ARE AN EQUAL OPPORTUNITY EMPLOYERWord data disk/HR FORMS/Corporate ApplicationR/04/01/2014COAL COUNTY GENERAL HOSPITAL, INC.D/B/AMary Hurley HospitalCOAL COUNTY EXTENDED CARE, INC.D/B/A Ruth Wilson Hurley Manor6 N. Covington St.P.O. Box 326Coalgate, OK 74538( )_________ ( )________ ( )________ ( )__________ ______-_____-_____Are you under YesThe age of 18 NoAre you authorized to YesWork in the U.S.? NoHow did you hear about this Job Opportunity?Postings____ Newspaper____ Friend____Employee____ Job Fair (Where) ________________Other______________________________________Are you able to perform the duties of the job with or without reasonable accommodation? Yes NoHave you ever been convictedof a felony?Yes NoConviction will not necessarily disqualify an applicant from employmentHave you ever been employed/applied with Coal County General Hospital/CoalCounty Extended Care?Yes NoList relatives currently employed with Coal County General Hospital/Coal County Extended Care_________________________Where/When___________________________
List your employers for the last ten yearsbeginning with the most recent. Include as a separate item, all periods of unemployment exceeding ninety (90) days, military service and schooling. A resume will not be accepted in lieu of the completed Work History section of this application.WORK HISTORYProfessional References-Familiar with work performed (At least two Professional-Non-RelativeSIGNATUREI hereby authorize Coal County General Hospital, Inc. and/or Coal County Extended Care, Inc. to obtain from my former employers all data and records, including the same from a consumer-reporting agency needed to support this application. I hereby release my former employers and individuals connected therewith, and further release Coal County General Hospital, Inc. and/or Coal County Extended Care, Inc. from all liability for any damage whatsoever incurred in furnishing such information. I hereby certify that the foregoing statements are to the best of my knowledge true and correct, and I agree that
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- Fall '15
- Tammy Eades
- Coal County General Hospital, Coal County Extended Care