Employment Opportunities

General Information

First Name *	Last Name *
Street *	City *
State *	Zip * County *
Phone *	Email
Date of Birth *	Professional License # & Issuing State *

Certifications & Employment Questions

A: What position are you applying for? * Location Applying For? *
B: Current CPR? *	Yes No
C: Current TB? *	Yes No
D: Are you currently employed? *	Yes No
E: May we contact your present Employer? *	Yes No
F: Have you ever submitted an application with SHP? *	Yes No
G: Have you ever been convicted of a crime? *	Yes No
H: Have you ever had a professional license revoked, reviewed, suspended or limited in any way? *	Yes No
If you answered YES to F, G, or H, please explain:

Education

School	Name	Year Graduated	Degree Received	Course of Study
High School
Technical School
College/University
Other

Employment History

Please start with your present or most recent position.

Position 1

Employer	Employment Dates
Date Left Employment	Supervisor Name & Phone Number
Hourly Rate	Reason(s) for Leaving
Duties Performed

Position 2

Employer	Employment Dates
Date Left Employment	Supervisor Name & Phone Number
Hourly Rate	Reason(s) for Leaving
Duties Performed

Position 3

Employer	Employment Dates
Date Left Employment	Supervisor Name & Phone Number
Hourly Rate	Reason(s) for Leaving
Duties Performed

Terms

Southern Health Partners is dedicated to a Drug Free Workplace. A urinalysis will be obtained in the final stages of the employee selection process for the purpose of determining substance use. By submitting this application I agree that Southern Health Partners may collect these specimens for the tests and if necessary may forward them to a third party testing facility for analysis. I further agree to, and hereby authorize, the release of the results of said tests to Southern Health Partners. I understand that the current use of drugs and/or alcohol shall prohibit me from being employed by Southern Health Partners. I further agree to hold harmless this company and its agents from any liability arising in whole or in part from the collection of specimens, testing and use of the results from said tests in connection with the company's consideration of my application for employment.

I understand a condition of my employment may be based on the issuance of a security clearance to work within a jail facility. I may be asked to have a background investigation performed. If I am denied a security clearance, any offer of employment will be withdrawn immediately without any obligation or liability to me other than for payment at the rate agreed upon for any services actually rendered. Further, I hereby authorize investigation of all statements contained herein and agree that if any material or willful misrepresentation or omission has been made by me, Southern Health Partners, Inc will withdraw any offer of employment immediately without any obligation or liability to me. Further, I also understand no supervisor, manager, or other representative of Southern Health Partners has any authority to enter into any express or implied contract for employment. Any employment contract must be in writing and must be signed by the Vice President or President of the Company.