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First Name:
Middle Name:
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Home Address
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Personal Information
Last 4 Digits of Your Social Security Number:
Have you ever applied for employment with us?
If yes: Month and Year
Have you ever been employed by Atlantic General Hospital or Health System before?
If yes: Please give dates
Location:
Pay Expected:
Are you legally eligible for employment in the United States?
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Yes
No
Have you ever been convicted of a felony and/or misdemeanor?
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Yes
No
If yes, please explain.
When will you be available to begin work?
Status desired and days and hours available to work.
Please check all that apply.
Full time
Part time
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1st Shift
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3rd Shift
Monday
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Wednesday
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Sunday
Are you available to work overtime?
Yes
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Other special training or skills
(languages, machine operation, etc.)
Referred by:
Education Information
College
Name of School
Location of School
Course of Study
Number of Years Completed
Did you graduate?
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Yes
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Degree or Diploma:
High School
Name of School
Location of School
Course of Study
Number of Years Completed
Did you graduate?
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Yes
No
Degree or Diploma:
Other
Name of School
Location of School
Course of Study
Number of Years Completed
Did you graduate?
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Yes
No
Degree or Diploma:
Employment History
Employer 1
Company Name:
Telephone:
Address:
Employed (month and year)
From:
To:
Name of Supervisor:
Weekly Pay:
Job Title:
Reason for leaving:
Describe your work:
May we contact this employer:
Yes
No
Employer 2
Company Name:
Telephone:
Address:
Employed (month and year)
From:
To:
Name of Supervisor:
Weekly Pay:
Job Title:
Reason for leaving:
Describe your work:
May we contact this employer:
Yes
No
Employer 3
Company Name:
Telephone:
Address:
Employed (month and year)
From:
To:
Name of Supervisor:
Weekly Pay:
Job Title:
Reason for leaving:
Describe your work:
May we contact this employer:
Yes
No
Employer 4
Company Name:
Telephone:
Address:
Employed (month and year)
From:
To:
Name of Supervisor:
Weekly Pay:
Job Title:
Reason for leaving:
Describe your work:
May we contact this employer:
Yes
No
Employer 5
Company Name:
Telephone:
Address:
Employed (month and year)
From:
To:
Name of Supervisor:
Weekly Pay:
Job Title:
Reason for leaving:
Describe your work:
May we contact this employer:
Yes
No
Employer 6
Company Name:
Telephone:
Address:
Employed (month and year)
From:
To:
Name of Supervisor:
Weekly Pay:
Job Title:
Reason for leaving:
Describe your work:
May we contact this employer:
Yes
No
Resume (optional) - .doc, .pdf or .txt only.
Attach File:
PLEASE READ CAREFULLY AND CLICK "I AGREE" BEFORE SUBMITTING YOUR APPLICATION I hereby certify that all of the information provided by me in this application (or any other accompanying or required documents) is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts in said documents will be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery. I understand that submission of an application does not guarantee employment. I further understand that, should an offer of employment be extended by Atlantic General Hospital Corporation (hereinafter referred to as "Atlantic General Hospital") that such employment with Atlantic General Hospital is at will, for no specified duration and may be terminated by either Atlantic General Hospital or myself at any time, with or without cause. I understand that none of the documents, policies, procedures, actions, statements of Atlantic General Hospital or its representatives used during the employment process is deemed a contract of employment real or implied. I understand that no representative of Atlantic General Hospital except the President/CEO has the authority to enter into any agreement guaranteeing any conditions of employment or any agreement contrary to the foregoing statements and that any such agreements must be made in writing and signed by the President/CEO of Atlantic General Hospital. In consideration for employment with Atlantic General Hospital, if employed, I agree to conform to the rules, regulations, policies and procedures of Atlantic General Hospital at all times and understand that such is a condition of employment. I understand that due to the nature of Atlantic General Hospital's business, attendance and punctuality are considered essential requirements of every job at Atlantic General Hospital and that poor attendance or tardiness will result in disciplinary action. I understand that if offered a position with Atlantic General Hospital, I may be required to submit to a pre-employment medical examination, drug screening and background check as a condition of employment. I understand that unsatisfactory results from, refusal to cooperate with, or any attempt to affect the results of these pre-employment tests and checks will result in withdrawal of any employment offer or termination of employment if already employed. I hereby authorize any and all schools, former employers, references, courts and any others who have information about me to provide such information to Atlantic General Hospital and/or any of its representatives, agents or vendors and I release all parties involved from any and all liability for any and all damage that may result from providing such information. I understand that this application is considered current for 12 months. If I wish to be considered for employment after this period I must complete and submit a new application. BY CLICKING "I AGREE" BELOW, I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ABOVE STATEMENTS. ATLANTIC GENERAL HOSPITAL IS PROUD TO BE AN EQUAL OPPORTUNITY EMPLOYER. ALL QUALIFIED APPLICANTS WILL RECEIVE CONSIDERATION WITHOUT REGARD TO RACE, COLOR, RELIGION, GENDER, NATIONAL ORIGIN, AGE, DISABILITY, VETERAN STATUS OR ANY OTHER STATUS PROTECTED BY LAW. UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.
I have read and agree to the terms and conditions stated above.
Emergency Room
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Lab Service
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X-Rays
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