Employment Application
An Equal Opportunity Employer

*denotes required field  
 
Applicant Information
Date:
   
*Full name:
Last, First, Middle
Social security number:
 
    
*Street address:
P.O. Box:
Apt. #:
 
City:
  
State:
 
Zip:
 
County:
  
    
*Phone number:
  
  
Additional phone:
   
Cell phone:
  
Email:
*Position desired:
 First choice
Position desired:
 Second choice
Attach resume:
 Optional
   
Location
*Which location(s) are you applying for?
SRHS Corporate Office
Trousdale Medical Center
Trousdale EMS
Sumner Regional Medical Center
Riverview Regional Medical Center
Dekalb EMS
Sumner Homecare & Hospice
 Other:
   
Referral
*What or who first attracted you to seek employment with SRHS?
Employee referral:
Career fair:
Newspaper:
Professional journal:
Website:
   
Recruitment:
Clinical rotation      Direct mail       School visit
On site:
Visiting a patient    Being a patient
Other:
   
Employment
List most recent employer first. *Note, please provide personal references if you don't have prior employment history.
*May we contact your present employer?
*Name of employer:
Phone:
Address:
County:
City:
  
State:
 
Zip:
Supervisors name/title:
Job titles and duties:
Employed (month/year):
 to        Ending rate of pay:
Hours per week:
     Full-time    Part-time    PRN (as needed)    Temp
*Status:
Present employer
Discharged
Resigned with notice
Resigned without notice
Layoff
Other
 Explain:
*Name of employer:
Phone:
Address:
County:
City:
  
State:
 
Zip:
 
Supervisors name/title:
Job titles and duties:
Employed (month/year):
 to        Ending rate of pay:
Hours per week:
     Full-time    Part-time    PRN (as needed)    Temp
Status:
Present employer
Discharged
Resigned with notice
Resigned without notice
Layoff
Other
 Explain:
Name of employer:
Phone:
Address:
County:
City:
  
State:
 
Zip:
 
Supervisors name/title:
Job titles and duties:
Employed (month/year):
 to        Ending rate of pay:
Hours per week:
     Full-time    Part-time    PRN (as needed)    Temp
Status:
Present employer
Discharged
Resigned with notice
Resigned without notice
Layoff
Other
 Explain:
Name of employer:
Phone:
Address:
County:
City:
  
State:
 
Zip:
 
Supervisors name/title:
Job titles and duties:
Employed (month/year):
 to        Ending rate of pay:
Hours per week:
     Full-time    Part-time    PRN (as needed)    Temp
Status:
Present employer
Discharged
Resigned with notice
Resigned without notice
Layoff
Other
 Explain:
If employed under a name other than the one given in the first section, list employer and name used:
*Have you ever been discharged or asked to resign from a job because of alleged negligence, neglect, or violation of employer's policy and procedures?
If yes, please explain:
   
Education
*Select highest grade completed:
  Elementary school
      
 
High school
        
 
College
 1    2     3      4    5    6
College/University:
    
Address:
    
Major course of study:
Degree/diploma received:
College/University:
    
Address:
    
Major course of study:
Degree/diploma received:
High school:
    
Address:
    
Major course of study:
Degree/diploma received:
Other:
    
Address:
    
Major course of study:
Degree/diploma received:
Memberships of positions held in professional or civic organizations, which you consider relevant to the position for which you have applied.
   
Personal
Previous mailing address (within the past 5 years):
Street address:
P.O. Box:
Apt. #:
 
City:
  
State:
Zip:
 
County:
  
To allow a full background check, list any addresses you have lived at in the last seven years:
*Are you authorized to work in the United States?
*Are you at least 18 years of age?
Shifts available:
1st shift
2nd shift
3rd shift
7 a.m. to 7 p.m.
7 p.m. to 7 a.m.
Any
 Other:
(check all that apply)
 
*Are you available if required?:
Holidays
 
Overtime
 
Weekends
*Employment interests:
Full-time
Part-time
  
PRN (as needed)
Weekends
(check all that apply)
Notice required at current employer?
Date available to begin?       Minimum salary desired:
*Were you previously employed with SRHS?   
  If yes, complete the following.
Location:
SRHS Corporate Office
Trousdale Medical Center
Trousdale EMS
Sumner Regional Medical Center
**Riverview Regional Medical Center
Dekalb EMS
Sumner Homecare & Hospice
           **(formerly Carthage General Hospital and Smith County Memorial Hospital)
 Other:
Employed (month/year):
Position/department:
Status:
Resigned
Discharged
Other
Please explain:
 
*Relatives employed with SRHS?   
  If yes, complete the following.
Name:
     Relationship:
Department/facility:
*Have you ever plead guilty or been convicted of a misdemeanor or felony crime or had a judgment withheld?
Convictions are not necessarily a bar to employment. If yes, please explain:
*Are you listed by a federal agency as debarred, excluded or otherwise ineligible for participation in federally funded health care programs?
If yes, please explain:
*Have you ever been convicted of a health care related criminal offense?
If yes, please explain:
Applicants with professional license or registration
Type of license/registration:
Current license/registration #:
Expiration date:
State:
 Other state recognized:
Has your professional license in this state or another state, been suspended, limited, revoked or subjected to disciplinary action?

If yes, please explain:
Driver's license (if required)
Driver's license #:
Expiration date:
State:
Has license ever been revoked?
If yes, why:
Complete this section if you have served in the U.S. Armed Forces
Branch of service:
      Period of active duty:
Describe duties, relevant training and rank at discharge:
 
Skills Checklist
Please select areas of skill by specifying years of experience.
Nursing Skills
Allied Health Skills
Software
Nursing
Laboratory
Word
Med/Surg
Microbiology
Excel
Pediatrics
Chemistry
Access
Geriatrics
Hematology
PowerPoint
Critical Care
Blood Bank
Outlook
           Coronary Care
General Laboratory
Internet Explorer
           Surgical Intensive Care
Client Services
Meditech
           Trauma
Phlebotomy
Accounting/Patient Finance
Telemetry
Medical Imaging
10 Key
Newborn Nursery
Diagnostic Radiology
Accounts Payable
        Well Baby
CT
Accounts Receivable
        NICU
MRI
Trial Balance
Labor & Delivery
Ultrasound
General Ledger
Post partum
Nuclear Medicine
Financial Statement
Operating Room
Mammography
Payroll
        Endo
Radiation Therapy
Collections
        Scrub
Medical Dosimetry
        Government Insurance
        Circulator
Cardiovascular Lab
        Private Insurance
PACU
Rehabilitation
        Self-Pay
Emergency Department
Occupational Therapy
CPAR
Home Health/Hospice
Physical Therapy
Service
Long-Term Care
Speech Therapy