╨╧рб▒с>■  ■                                                                                                                                                                                                                                                                                                                                                                                                                                                   ¤   ■   ■   ■   ■                                                                                                                                                                                                                                                                                                                                                                                                                                                            Root Entry        ┬█═(т ╬вЪкJrаЎGя┼┼└MatOST        атz я┼┼РВ я┼┼MM            MN0     ■   ■                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       ND■      ┬█═(т ╬вЪкJrMicrosoft Works MSWorksWPDocЇ9▓qScotland County Memorial Hospital Employment Application --------------------------------------------------------------------------------------------------------------- авэя35su┬─їўSиc╟)+p─╞ RRTЯб╚5 7 q s н п щ ы / o q ╣ ╗ ■ D е з х ч ч % ' e g е з ь 2 В Д ╬ ╨ ▓┤їRTа▀3UйЁ11lоў<╠╬╬&аRч 1╬'()*+Georgia Cooper Black╨h ┐┴ ар=╨/╨8 ар=╨/╨8de / University 1 2 3 4 ___________ _______ Name of last school attended ________________ address _____________ Degree / Profession / Nursing / Technician / License/ certification /registratioCompObj            U                                    _______________________________________ Armed Services/Guard/Reserves? Yes__ No__ Branch__________Rank____ Discharge date_______ duties_________________________________ Relatives currently working at SCMH? No___ Yes___ Name? ___________ Have you ever been convicted of a felony crime? No____ Yes_____ Work History (Last 4 employers, beginning with the most recent) Dates Name/Address Position Reason for leaving ______ ______________________ _________ _________________ ______ ______________________ _________ _________________ ______ ______________________ _________ _________________ ______ ______________________ _________ _________________ Business Skills: (Please check) Word Processing __ W.P.M. ______ Familiar with medical terminology ___ IC coding ___ Ward clerk ___ Office ___ Insurance filing ___ Medicare ___ Computer Skills: yes__ No __ Other skills that you believe would be helpful _________________________ I, _________________________ give my consent & p■ХS╜╜а░TЫ╨┐╬  ",,,, ар=╨/╨8d,    ╨╠tЩ,ETScotland County Memorial Hospital Employment Application --------------------------------------------------------------------------------------------------------------- Name____________________________________________________ (Last) (First) (MI) Address__________________________________________________ State_______ ZIP________ Day Time Phone ( )________________ Evening Phone ( )_____________ Citizen of USA (yes)_____ (no)_____ Social Security No. ____________ under 17 years?____ over 70 years?_____ Position applied for: _____________ Date available for work:___________ (emergency contact) Name _____________________relationship _______ address ____________________________ phone _________________ Prior work history this institution? No____ Yes____ Position held_________ dates worked _____________ / __________________ Education: (highest grade completed) graduation year major Elementary School 5 6 7 8 ___________ High School 1 2 3 4 ___________ Vo/Tech/Business 1 2 3 4 ___________ _______ Comm. College 1 2 3 4 ___________ _______ College / University 1 2 3 4 ___________ _______ Name of last school attended ________________ address _____________ Degree / Profession / Nursing / Technician / License/ certification /registration: Name, Level, or Description ____________________________________ License / Registration Number ____________ State / National _________ Expiration Date _______ Current Reciprocity or Re-activation? ___________ Please list 3 Professional References Name address phone ________________________________________________________ ________________________________________________________ ________________________________________________________ Armed Services/Guard/Reserves? Yes__ No__ Branch__________Rank____ Discharge date_______ duties_________________________________ Relatives currently working at SCMH? No___ Yes___ Name? ___________ Have you ever been convicted of a felony crime? No____ Yes_____ Work History (Last 4 employers, beginning with the most recent) Dates Name/Address Position Reason for leaving ______ ______________________ _________ _________________ ______ ______________________ _________ _________________ ______ ______________________ _________ _________________ ______ ______________________ _________ _________________ Business Skills: (Please check) Word Processing __ W.P.M. ______ Familiar with medical terminology ___ IC coding ___ Ward clerk ___ Office ___ Insurance filing ___ Medicare ___ Computer Skills: yes__ No __ Other skills that you believe would be helpful _________________________ I, _________________________ give my consent & permission for release of any information obtained from a personal background search (within guide lines of the law), to this facility only, as part of this application process. _________________________________ __________________ Signature Date Where did you hear about this position? W.O.M. ___ Newspaper ___ TV ___ Web ___ employment center ___ radio ___ other ___ none ___ ---------------------------------------------------------------------------------- please do not write in this area ---------------------------------------------------------------------------------- Preliminary interview by: _________________________ Date_________ Testing / Skills: _____________________________________________ Comments: _______________________________________________ Final interview by: ______________________________ Date________ Wage rate _______ Shift differential_______ Hrs / Wk.____ Ft.___ Pt.___ Temporary Employee Hire _______ Permanent Employee Hire _________ Entry Level __________________ Anniversary Date ________________ This application to be kept (active/on-file) From _________ Until ________ 2 3 4 __________╜ўб╚ ╬{wrwrwrw( L╜┐┴├¤АВ╜┐TVаqaQqр└!р└! р└!