Application for Employment

King's Daughters Medical Center

Application for Employment

This application shall become inactive after 1 year, but may be reactivated for an additional 1 year by written request of the applicant.

"Equal opportunity is given to all applicants regardless of race, creed, color, national origin, sex, age or individuals with disabilities."

When you are ready to begin, click the next button below. Please allow about 30-minutes to complete the application.

Personal Details

First Name

Last Name

Home Phone

Cell Phone

eMail Address

Street Address

City

State

Zip

Employee Verification

If offered a position, the Immigration Reform and Control Act of 1986 requires you to furnish proof of your employment authorization and your identity before you begin work.

Social Security Number

Have you ever worked under any other name or SSN? please explain

Are you over the age of 17 ? Yes No

Are you a either a US citizen or an alien who has the legal right to work in the job for which you are applying? Yes No

Criminal history record checks will be required as provided by and conducted in accordance with Mississippi Code Annotated Section 43-11-13 and the "Minimum Standards of Operation for Mississippi Hospitals" adopted by the Mississippi State Department of Health, Health Facilities and Certification Division.

Have you ever been convicted of a crime? Yes No

Crime explanation

Education Details

High School

High School Name

City

State

Diploma Yes No

Primary College

Enter your primary college details here:

College Name

City

State

Comments

Degree

Graduated? Yes No

Secondary College

Enter your secondary college details here:

College Name

City

State

Comments

Degree

Graduated? Yes No

Graduate School

Enter Graduate School details here:

Graduate School Name

City

State

Comments

Degree

Graduated? Yes No

Special Training School

Enter any special training classes here:

School Name

City

State

Comments

Degree

Graduated? Yes No

Work History

Please enter your work history details in the following sections starting with your most recent.

Most Recent Employment

Company Name

Phone Number

Company Address

Dates of employment

From

To

Salary

Supervisor's Name

Your final position

Job duties

Reason for leaving

Eligible for rehire? Yes No

Second Most Recent Employment

Company Name

Phone Number

Company Address

Dates of employment

From

To

Salary

Supervisor's Name

Your final position

Job duties

Reason for leaving

Eligible for rehire? Yes No

Third Most Recent Employment

Company Name

Phone Number

Company Address

Dates of employment

From

To

Salary

Supervisor's Name

Your final position

Job duties

Reason for leaving

Eligible for rehire? Yes No

Fourth Most Recent Employment

Company Name

Phone Number

Company Address

Dates of employment

From

To

Salary

Supervisor's Name

Your final position

Job duties

Reason for leaving

Eligible for rehire? Yes No

Military Experience

Please enter any previous military experience details below:

Military Branch

Dates of Service

From

To

Rank Achieved

Please describe any special schools or training

Licensure

Please enter details about your licensure below:

Primary Licensure

License Type

State

License Number

Licensure Dates

Secondary Licensure

License Type

State

License Number

Licensure Dates

Other Licensure

License Type

State

License Number

Licensure Dates

Agreement Terms - Please READ CAREFULLY

I certify that the answers given by me to the foregoing questions and statements are true and complete to the best of my knowledge, and that I have withheld nothing that would, if disclosed, affect this application unfavorably. I acknowledge that misrepresentation or omission of facts called for in this application is cause for my not being hired or my termination at any time without previous knowledge to me.

I authorize the hospital, or its agent, to obtain any information about my work history or personal information, including my character and qualifications, credit rating, driving record, criminal record, education and previous employment. I authorize all persons, schools, companies, information service bureaus, governmental agencies and law enforcement authorities to release any information concerning my background to the hospital, whether or not it is in their records. I also authorize the hospital to obtain this information from any company that is in the business of providing applicant background checks. I hereby release the individuals or entities providing this information from all liability or any damage caused by issuing this information.

I agree to submit myself upon request by the hospital, subsequent to a conditional job offer, for physical examination by a physician designated by the hospital, and to future physical or mental examinations the hospital may require at a later date as a condition of continued employment, as may be permitted by law.

If employed, I agree as a condition of continued employment to acquaint myself with, and to abide by all Rules, Regulations and Policies as established or amended by the hospital. However, I understand that my employment and compensation can be terminated with or without notice at any time, and for any reason, at the option of the hospital or myself. Nothing in this Application of Employment should be construed to consitute a contract of employment between the hospital and the applicant. I understand that my terms and conditions of employment may be changed at any time.

If you understand and agree to the above terms, check below. I Agree With These Terms
I Disagree With These Terms
*

Thank you for your application. Your information has been transmitted to:

King's Daughters Medical Center

Human Resources Department

If you have a resume you would like to send in addition to this application, you can send it via email or fax:

humanresources@kdmc.org
601-835-9183 (fax)