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					                             APPLICATION FOR EMPLOYMENT

                          Note: Please fill out this form and fax to 706-208-0806

We consider applicants for all positions without regard to race, color, religion, national
origin, age, the presence of a non-job-related medical condition, marital or veteran
status, or any other legally protected status.

Last Name                   First Name             Middle Name               Date of Application

Address                                            City              State              Zip Code

Home Telephone               Other number where you can be reached           Social Security Number

Position(s) Applied For                            Expected Pay

Referral Source
Advertisement               Friend              Walk-in
Employment Agency           Relative            Other _______________

Date of Birth : _______________ (Submission of date of birth is voluntary)

Are you employed now?         Yes      No

May we contact your present employer?       Yes         No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?
        Yes No

On what date would you be available for work? __________            Full Time       Part Time

Can you travel if a job requires it?       Yes          No

Have you been convicted of a felony within the last 7 years?       Yes  No
(Conviction will not necessarily disqualify an applicant from employment)
If Yes, please explain ___________________________________________________________
                                             - Continue to next page –
                           FOR PERSONNEL DEPARTMENT USE ONLY
Remarks : ____________________________________________________________________
Personnel Test Score : __________________________________________________________
Accepted for employment : Yes       No         Position : __________________________
Starting Rate : $ __________per ____________ (hour, week, year) Begin Date: __/__/__
Interviewed by : ___________________________         Date : __/__/__

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Specialized Skills : Copier Fax Calculator Computer Microsoft Word
Microsoft ExcelMicrosoft Access Microsoft Outlook Typing Speed ____/wpm
EKG equipment Draw blood
Other Qualifications:
Summarize special jog-related skills and qualifications acquired from employment or other experience.

Employment Experience
Start with your present or last job. Include military service assignments and volunteer activities. You may
exclude organization names which indicate race, color, religion, gender, national origin, handicap or
other protected status.

Employer                                Dates Employed                 Work Performed


Telephone Number(s)                     Start Hourly Rate/Salary

Job Title                               Final Hourly Rate/Salary

Supervisor                              Reason for leaving

Employer                                Dates Employed                  Work Performed


Telephone Number (s)               Start Hourly Rate/Salary

Job Title                          Final Hourly Rate/Salary

Supervisor                         Reason for leaving

Employer                           Dates Employed                       Work Performed


Telephone Number (s)              Start Hourly Rate/Salary

Job Title                         Final Hourly Rate/Salary

Supervisor                        Reason for leaving

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High School                             Location                              Diploma/Degree

College/Technical                      Location                               Diploma/Degree

Graduate/Professional                  Location                               Diploma/Degree

Give name, address and telephone number of three references who are not related to you and are not
previous employers.




Applicant’s Statement

”I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all
statements contained in this application for employment as may be necessary in arriving at an employment decision.
In some cases we may use an outside firm to check your references. If we do so, we will supply you with the name of
the firm conducting the check. This application for employment shall be considered active for a period of time not to
 exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to
whether or not applications are being accepted at that time. The applicant understands that neither this document nor
an offer of employment from the employer constitute an employment contract unless a specific document to that effect
is executed by the employer in writing. In the event of employment, I understand that false or misleading information
given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all
rules and regulations of the employer.”
“I have read and fully understand the foregoing and voluntarily consent to allow Athens Heart Center to check my
references by contacting any person whom they deem to be an appropriate reference. Questions may be asked about
my personal background, work experience, personality, personal habits and education.” I further authorize Athens Heart
Center to conduct a criminal background check and request a credit history report on myself.

Signature of Applicant : ____________________________                             Date: ______________

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