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	May 17, 2008

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On-line Job Application

Fill out the following form completely. All fields that contain the * next to them are required.

Personal
Name	First Name:	*
	Last Name:	*
	Middle Initial:

Address	Street:	*
	City:	*
	State:	*
	Zip:	*

	Phone:	*
	E-mail:

Other	Are you a U.S. citizen or do you hold a U.S. permanent residence visa?	Yes No *
	If not, what kind of visa do you hold?

	How did you hear about this opportunity?	*

	Were you ever convicted of a felony?	Yes No *
	(If yes), explain.

	Have you been subject of any adverse action(s) by any duly authorized sanctioned or disciplinary agency for either conduct-based or performance-based actions?	Yes No *

	Are you currently sanctioned, debarred, have a revoked or suspended licensure, or any other event that may make you ineligible for employment by a health care provider?	Yes No *

	Position Applied For:	*
	Facility Location(s) Willing To Work:	*
	Salary range expectation:	*
	Date available to work:	*


	Have you previously worked with ARH?	Yes No *
	If so, what location:
	Previously Employed:	From To



Education

High School	Name and Address:	*
	Course of study:	*
	Last year completed:	*
	Did you graduate?	Yes No *
	List diploma or degree:	*

College	Name and Address:
	Course of study:
	Last year completed:
	Did you graduate?	Yes No
	List diploma or degree:

College	Name and Address:
	Course of study:
	Last year completed:
	Did you graduate?	Yes No
	List diploma or degree:

	Other education:
	Area of specilization or major interest:


Licenses
	Are you currently:	Registered
		Licensed
		Certified

	Eligible for:	Registration
		Licensure
		Certification

If licensed, registered, or certified:
	Type:
	State issued:
	Date:
	Number:

	Type:
	State issued:
	Date:
	Number:

	Type:
	State issued:
	Date:
	Number:


Previous Experience
Job1	Name:
	Street/PO Box:
	City:
	State:
	Zip:
	Phone:
	Employed:	From To
	Pay:	Start End
	Title/Duties:
	Reason for leaving:
	Last supervisor:

Job2	Name:
	Street/PO Box:
	City:
	State:
	Zip:
	Phone:
	Employed:	From To
	Pay:	Start End
	Title/Duties:
	Reason for leaving:
	Last supervisor:

Job3	Name:
	Street/PO Box:
	City:
	State:
	Zip:
	Phone:
	Employed:	From To
	Pay:	Start End
	Title/Duties:
	Reason for leaving:
	Last supervisor:
	May we contact your present employer?	Yes No *

Military

	Did you serve in the U.S. Armed Services?	Yes No *

Special Skills

	Name your special skills (operation of office machines, Lab equipment, etc.):

	Can you type?	Yes No
	(If so) WPM

	Do you take short hand?	Yes No
	(If so) WPM:


References
Professional References Only
Reference 1	Name:	*
	Title:	*
	Company and address:	*
	Phone:	*
	Email:

Reference 2	Name:	*
	Title:	*
	Company and address:	*
	Phone:	*
	Email:

Reference 3	Name:	*
	Title:	*
	Company and address:	*
	Phone:	*
	Email:

An Equal Opportunity Employer
It is the policy of Appalachian Regional Healthcare, Inc., (ARH) to provide equal employment opportunity to all employees and applicants for employment regardless of their race, color, sex, religion, age, national origin, political afiliation, diabling condition or service in the uniformed services, in accordance with applicable law. This policy applies to all terms an conditions of employment, including, but not limited to, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.
Remarks
It is understood and agreed that any misrepresentation by me in this application will be sufficient cause for cancellation of the application and/or for separation from the company's service if I have been employed and that employment may be subject to satifactory physical examination by company physician. It is agreed that the company, at its option, may request an investigative report by a consumer reporting agency which will contain information with regard to the facts stated above and to my character, general reputation, personal characteristics and mode of living, whichever are applicable, and I may, by written request, obtain a complete and accurate disclosure of the nature and scope of the Company's request to such an agency. I voluntarily give Appalachian Regional Healthcare permission to make a thorough investigation of my educational background and past employments and all other facts within my application for employment and release from liability or responsibility all persons, places of business and municipalities supplying such information. A photographic copy of this authorization is to be considered acceptable. In making application for employment, I agree to abide by the policies and procedures of this Corporation and hospital provided that I do not abrogate any of my civil rights. I hereby pledge that, for a period of five (5) years following termination of my employment, I will not either individually or as a partner, enter into a business which would be in direct competition with Appalachian Regional Healthcare, Inc., using knowlege and skills obtained during my employment with Appalachian Regional Healthcare, Inc. I certify that I have read an fully understand the above statements.

ARH is
An Equal Opportunity Employer

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Please send resumes to:
Debbie Fugate
Appalachian Regional Healthcare
100 Airport Gardens Road
Hazard, KY 41701

PHONE: 606-487-7532
FAX: 606-487-7515

You may also email them to: .

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