* Are you legally eligible to be employed in the United States? (Proof of identity and eligibility will be required upon employment):

Yes   No

* Are you at least 18 years or older? (If no, you may be required to provide authorization to work):

Yes   No

* Have you ever been convicted or plead guilty to a misdemeanor or felony? (A conviction or guilty plea will not necessarily result in the denial of employment):

Yes   No

If Yes, please explain:

* Do you have relatives employed with The Hughston Clinic, Hughston Foundation, or Hughston Surgical Center or Jack Hughston Memorial Hospital?

Yes   No

If yes, please provide name and how you are related:

* Have you ever worked for this Company before?:

Yes   No

If Yes, please provide details (Where/When/Job Title):

* Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?:

Yes   No

If no, please explain:

* How did you hear about this job?:

Indeed.com   Friend   Relative   Simplyhired.com   Other   Department of Labor   Employee Referral   Job Fair

If you were referred to this job by an employee, please list their name:

If you attended a job fair please list the name of job fair attended:

* When would you be available to begin work?:

* Type of employment desired:

Full-Time Part Time PRN

* Hourly rate/salary desired:

* Are you currently employed?:

Yes   No

If so may we inquire of your present employer?:

Yes   No

If presently employed, why are you considering leaving?:

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School Name & Location	Did you Graduate? If not, how many years did you complete?	Degree Received	Subjects Studied/Major
*	*	*	*
*	*	*	*
*	*	*	*

If you have completed any special courses, seminars and/or training that would help you to perform the position for which you are applying, please describe:

Give your full employment record, starting with your current or most recent employment

* From:

* To:

* Employer Name & Address:

* Employer Phone:

* Job Title:

* Supervisor Name & Title:

* Duties:

* Reason for Leaving:

* Hourly Rate / Salary:

* From:

* To:

* Employer Name & Address:

* Employer Phone:

* Job Title:

* Supervisor Name & Title:

* Duties:

* Reason for Leaving:

* Hourly Rate / Salary:

* From:

* To:

* Employer Name & Address:

* Employer Phone:

* Job Title:

* Supervisor Name & Title:

* Duties:

* Reason for Leaving:

* Hourly Rate / Salary:

Name	Relationship	Phone Number
*		*
*		*
*		*

The facts set forth in this application and any supplemental information is true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be considered sufficient cause for immediate discharge. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me. If I am hired, I understand that either the company or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of the company has the authority to make any assurance to the contrary.

I understand that I am required to abide by all rules and regulations of the company.

* Signature (type name):

* Date: