Secure Application for Employment
Human Resources Department
14600 St. Stephens Avenue
Chatom, Alabama 36518
It is the policy of this facility to provide equal opportunity to persons regardless of race, religion,
age, gender, disability or any other classification in accordance with federal, state and local        
statutes, regulations and ordinances.                                                                                       
http://wchnh.fasthealth.com
email: 
Date
This application can be active as long as legally required.
Last Name                                    First Name                                  Middle Initial
   
Are You At Least 18 Years Old?

Date of Birth (Example: 10/23/1974)
Last 4 Digits of
Social Security Number


Home Phone
Cell Phone
Best Contact Method?
Present Address

Present City

Present State

Present Zip Code

E-Mail Address

Current Open Position(s) for Which You Are Applying



Type of Position
Full Time
PRN
Part Time
Shift Available

Weekend
Day
Night

Salary Requirement
$
If overtime work is required periodically, does this pose a problem for you?
Date Available For Work

Are You Legally Authorized to Work in the U.S.?
Have you ever worked in this facility?
If yes, when? Are you related to another facility employee or Board Member?
How did you learn about this position?
State Employment
         Commission

Internet
Job Listing
Ad
Current Employee
Other:

Are you able to perform the essential, job related functions of the position for which you are applying with or without reasonable accommodations?
Describe any accommodations necessary:

Have you ever been convicted of a misdemeanor or felony (other than traffic violation)?
If yes, explain:

Are you currently excluded from participation in any federally funded healthcare program - including Medicare and Medicaid - and are you
aware of any potential exclusion from a federally funded health program?
Educational History
Type of School
Name of School

City, State
Check Last Year
Attended in School

Degree or Certificate
High School
School:
    City:
   State:
9   10   11   12
Graduated/GED? Year
Degree:
College
School:
    City:
   State:
1     2     3    4
Graduated? Year
Degree:
College
School:
    City:
   State:
1    2    3     4
Graduated? Year
Degree:
Graduate
School

School:
    City:
   State:
1    2     3    4
Graduated? Year
Degree:
Other
School:
    City:
   State:
1    2    3    4
Graduated? Year
Degree:
Other
School:
    City:
   State:
1    2    3    4
Graduated? Year
Degree:
List any professional licenses, registration or certification you possess (Nursing or CNA, etc.); Include type, state issued, expiration date and number if applicable

Clerical or other skills applicable to the position for which you are applying
Typing (WPM)              PBX
Proficient in Software: 
Business machines and/or equipment you can operate:
      
Other