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Carlile Pediatrics
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Danny P Ingram
Elmore Community Hospital
Ivy Creek Enterprise
Ivy Creek Holtville
Ivy Creek of Millbrook
Ivy Creek Tallassee
Ivy Creek Troy
Ivy Creek Wetumpka
Ivy Creek Palliative Care
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Lake Martin Family Medicine
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Carlile Pediatrics
Chilton Urgent Care
Danny P Ingram
Elmore Community Hospital
Ivy Creek Enterprise
Ivy Creek Holtville
Ivy Creek of Millbrook
Ivy Creek Tallassee
Ivy Creek Troy
Ivy Creek Wetumpka
Ivy Creek Palliative Care
Lake Martin Community Hospital
Lake Martin Family Medicine
Physical Express
River Oak Medical
Wetumpka Pediatrics
Wetumpka Urgent Care Center
CNA Hospice (Elmore & Dadeville locations)
Ivy Creek Hospice Elmore
Ivy Creek Hospice Dadeville
Lake Martin Community Hospital
Elmore Community Hospital
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Full- Time Position
Pay range is $13 – $16
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Name
*
First
Last
Email
*
Phone
*
Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
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Iowa
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Maine
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Michigan
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Northern Mariana Islands
Ohio
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Pennsylvania
Puerto Rico
Rhode Island
South Carolina
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Utah
U.S. Virgin Islands
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Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
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State
ZIP Code
Name
*
First
Last
Relation
*
Phone
*
Shifts
*
Day
Night
Evening
Rotating
Specify type of work desired
*
Full-Time
Part-Time
Temporary
SUPP/PRN
Willing to work holidays?
*
Yes
No
Willing to work weekends?
*
Yes
No
Date you can begin?
*
MM slash DD slash YYYY
Are you legally able to work for all employers in the United States?
*
Yes
No
Highest Education Level Completed
*
High School
Undergraduate College
Graduate College
High School
High School Name
*
High School City
*
High School State
*
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
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Iowa
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
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Montana
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Northern Mariana Islands
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Rhode Island
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Tennessee
Texas
Utah
U.S. Virgin Islands
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Virginia
Washington
West Virginia
Wisconsin
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
High School Dates Attended
*
Did you graduate?
*
Yes
No
Diploma or Degree Received?
*
Yes
No
College
College 1: Name
*
College 1: City
*
College 1: State
*
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Kansas
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Maryland
Massachusetts
Michigan
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Northern Mariana Islands
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Tennessee
Texas
Utah
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Virginia
Washington
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Armed Forces Americas
Armed Forces Europe
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State
College 1: Dates Attended
*
College 1: Did you graduate?
*
Yes
No
College 1: Diploma or Degree Received?
*
Yes
No
College 1: Courses or Major
*
Did you attend a second college?
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Yes
No
Second College
College 2: Name
*
College 2: City
*
College 2: State
*
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
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Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
College 2: Dates Attended
*
College 2: Did you graduate?
*
Yes
No
College 2: Diploma or Degree Received?
*
Yes
No
College 2: Courses or Major
*
Did you attend a third college?
*
Yes
No
Third College
College 3: Name
*
College 3: City
*
College 3: State
*
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
College 3: Dates Attended
*
College 3: Did you graduate?
*
Yes
No
College 3: Diploma or Degree Received?
*
Yes
No
College 3: Courses or Major
*
Graduate School
Did you attend graduate school?
*
Yes
No
Grad School: Name
*
Grad School: City
*
Grad School: State
*
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Grad School: Dates Attended
*
Grad School: Did you graduate?
*
Yes
No
Grad School: Diploma or Degree Received?
*
Yes
No
Grad School: Courses or Major
*
Graduate hours
*
Nursing School
Did you attend nursing school?
*
Yes
No
Nursing School: Name
*
Nursing School: City
*
Nursing School: State
*
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Nursing School: Dates Attended
*
Nursing School: Did you graduate?
*
Yes
No
Nursing School: Diploma or Degree Received?
*
Yes
No
Nursing School: Courses or Major
*
Other Education
Any other school or training?
*
Yes
No
Other: Name
*
Other: City
*
Other: State
*
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Other: Dates Attended
*
Certification / Registration 1
Expiration Date 1
Certification / Registration 2
Expiration Date 2
Name of professional or trade organizations to which you belong
Community Hospital
Have you previously worked at Elmore Community or Lake Martin Community Hospital?
*
Yes
No
When?
*
If employed under a name different from above ( maiden name, nickname, ect. ) Please list
*
Do you have any friends and/or relatives employed at Elmore Community or Lake Martin Community Hospital?
*
Yes
No
Name 1
*
Relationship 1
*
Name 2
Relationship 2
Other
Have you ever been convicted of a felony?
*
Yes
No
Please Explain:
*
U.S. Military
Are you a veteran?
*
Yes
No
Dates of Service
*
Type of Duty
*
Service School or Special Training Received (When and What?)
*
Current / Most Recent Employer
Employer 1: Dates of Employment
*
Employer 1: Starting Salary
*
Employer 1: Current Salary
*
Employer 1: Company
*
Employer 1: Name (If Different)
Employer 1: Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employer 1: Job Title
*
Employer 1: Job Duties
*
Employer 1: Telephone Number
*
Employer 1: Supervisor's Name
*
Employer 1: Supervisor's Title
*
Employer 1: Reason for Leaving
*
Employer 1: May we contact this employer?
*
Yes
No
Why?
*
Add Additional Employer?
*
Yes
No
Second Previous Employer
Employer 2: Dates of Employment
*
Employer 2: Starting Salary
*
Employer 2: Current Salary
*
Employer 2: Company
*
Employer 2: Name (If Different)
Employer 2: Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employer 2: Job Title
*
Employer 2: Job Duties
*
Employer 2: Telephone Number
*
Employer 2: Supervisor's Name
*
Employer 2: Supervisor's Title
*
Employer 2: Reason for Leaving
*
Employer 2: May we contact this employer?
*
Yes
No
Why?
*
Add Another Additional Employer?
*
Yes
No
Third Previous Employer
Employer 3: Dates of Employment
*
Employer 3: Starting Salary
*
Employer 3: Current Salary
*
Employer 3: Company
*
Employer 3: Name (If Different)
Employer 3: Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employer 3: Job Title
*
Employer 3: Job Duties
*
Employer 3: Telephone Number
*
Employer 3: Supervisor's Name
*
Employer 3: Supervisor's Title
*
Employer 3: Reason for Leaving
*
Employer 3: May we contact this employer?
*
Yes
No
Why?
*
Office Equipment
Multi-Line Phone
Copy Machine
10-Key Calculator
Fax Machine
Filing Alphabetical
Filing Numerical
Data Entry
Medical Transcription
Medical Terminology
ICD-9-CM Coding
Hospital Housekeeping
Institutional Food Service
Inventory Control
Professional Floor Care
Typewriter:
WPM:
*
Computer Software
Word
Excel
dBase
Windows
Microsoft Office
Other Software:
Specify:
*
Operating Systems
Windows for Workgroups
Microsoft NT
DOS
Unix
Novell
Other OS
Networking
Programming:
What programing languages?
*
Miscellaneous Others:
General Clinical Skills
Quality Management
Staff
Patient
Student/Preceptor
IV Therapy
Venipuncture
Adult
Pediatric
Newborn
Patient Chart/Documentation
Vital Signs
Cardiac Monitoring
EKG
Nursing Skills
Central Sterile
Emergency
Endoscopy/OP Surgery
Intensive Care
SICU/CCU
Long-term Care
Medical/Surgical
OB/GYN/Neonatal/NICU
Oncology
Orthopedic/Neuro
Pediatrics
Psychiatric
Recovery (PACU)
Surgery
Telemetry
Laboratory Skills
Blood Bank
Chemistry
Cytology
Hematology
Histology
Microbiology
GXT9 (Graded Exercise Test)
STAT Lab
Urinalysis/Coagulation
Lab Equip./Instruments
Laboratory Testing,
Please list types of lab equipment, lab testing, and specimen analysis
Radiology Skills
CT
Mammography
MRI
Specimen Analysis
Nuclear Medicine
Ultrasound
Pharmacy Skills
IV Admixtures/Piggybacks/Syringes/Chemo
Patient Nutrition Support
Patient Discharge Consults
Automated Dispensing Equipment
Medication Dispensing
Oral/Liquid Medication Repacking Equip.
Describe nutrition support, IV, or repacking experience:
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I authorize any employer, school, or person named by me to release any information regarding me or my employment. I hereby release said individuals or organizations from liability for any damage for issuing such information. I certify that the answers given by me to the foregoing questions and statements are true and correct. Further,. any falsification, omission, or misrepresentation of information supplied by me, either orally or on any company document, will be sufficient cause for elimination from continued employment. I understand that neither this document nor any offer of employment from the employer constitutes an employment contract. Furthermore, I understand that any employment is “at will”, which means that either I or Elmore Community Hospital or Lake Martin Community Hospital may terminate my employment at any time with or without cause, reason, or notice. No manager or representative of Elmore Community Hospital or Lake Martin Community Hospital has any authority to enter into an agreement of employment for any specified length of time. In making this application for employment, I agree to submit to a post-offer pre-employment drug and health screen. Should the results of this be unsatisfactory in the judgement of Elmore Community Hospital or Lake Martin Community Hospital, the job offer will be withdrawn. If offered employment, Elmore Community Hospital and/or Lake Martin Community Hospital will be required to verify my identity and eligibility to work in the United States of America, in accordance with the Immigration Reform and Control Act. I understand that documents to verify my identity and eligibility for employment may be submitted in accor dance with regulations of the US Immigration and Naturalization Service. Submitting this information is an acknowledgement that I have read and understand this document. Elmore Community Hospital and/or Lake Martin Community Hospital is an equal opportunity employer. Elmore Community Hospital and/or Lake Martin Community Hospital considers applicants for all positions without regard to race, color, religion, sex, national origin, marital or veteran status, the presence of disability, or any other legally protected status.
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