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    Your Name*
    Phone*
    Present Address
    Street*
    City* State* Zip*
    Are you 18 or over?

    Job Interest

    Position desired*
    Date available*
    Shift preference
    Other

    If hired, you will be required to submit documents sufficient to establish employment authorization and identity in compliance with the Immigration and Reform Act of 1986.

    Ringgold County Hospital is an equal opportunity employer. We do not discriminate against persons in our employment practices because of race, color, sex, religion, age, national origin, or disability. We support all federal and state legislation regarding the absence of discrimination.

    Are you presently employed?
    Present or most recent employer:
    Employment dates: From to
    Name of employer
    Address
    Street
    City State Zip
    Phone
    Your position
    Last supervisor
    Starting salary Final salary
    Description of work performed

    Reason for leaving

    Next recent employer:
    Employment dates: From to
    Name of employer
    Address
    Street
    City State Zip
    Phone
    Your position
    Last supervisor
    Starting salary Final salary
    Description of work performed

    Reason for leaving

    Educational Record

    Post high school (i.e. college, school of nursing, vocational, technical or graduate level)

    Name and address of school
    Course of study
    Last year completed
    Did you graduate?
    Degree/Diploma

    Name and address of school
    Course of study
    Last year completed
    Did you graduate?
    Degree/Diploma

    Name and address of school
    Course of study
    Last year completed
    Did you graduate?
    Degree/Diploma

    Name and address of school
    Course of study
    Last year completed
    Did you graduate?
    Degree/Diploma

    High School

    Name and address of school
    Course of study
    Last year completed
    Did you graduate?
    Degree/Diploma
    Any further education information:

    Additional Information

    If applicable, list all professional licensure information: (one per line)
    If applicable, please list any other professional credentials that you feel would relate to the position for which you are applying (i.e. ACLS, BCLS, CPR):

    Please Read and Sign

    To the best of my knowledge, all of the information I have submitted on this application is true and complete. I understand that any omission or falsification of information will be sufficient cause for disqualification from further consideration for employment or for dismissal.

    I voluntarily give this organization the right to make a thorough investigation of my personal or past employment history and education, agree to cooperate in such investigation, and authorize any former employer, person, firm, or corporation to give this organization any information they may have regarding me. In consideration of this organization's review of this application, I release this organization and all providers of information from any liability as a result of furnishing and receiving this information. I understand that any offers of employment are contingent on successful completion of the post-offer exam and background checks.

    I understand employment of this organization is "at will," which means employment may be terminated by the employee or by this organization at any time, with or without cause. I further understand employee benefits, terms and conditions of employment and the policies, procedures and work rules of the organization may be determined, changed and modified from time to time by this organization without limitation or agreement. I also understand any employment handbooks or manuals that may be distributed to me by this organization shall not be construed as a contract.

    I hereby agree that if I become employed by this organization I consent to the release of all my future educational records involving classes, coursework, seminars and all other educational programs in which I am enrolled or attend and for which a portion or all of the enrollment fee or tuition will be paid by this organization to an accredited higher education institution. This consent will be effective on my date of employment and until I specifically revoke it in a signed and dated writing delivered to the higher education institution.

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