Careers

Application For Employment

Whatley Health Services Inc.

2731 Martin Luther King Jr. Blvd Tuscaloosa, AL 35401 (205)349-3250

We consider applications for all positions without regard to race, color, religion, creed, sex, national origin, disability, sexual orientation, citizenship status or any other legally protected status.

Position(s) Applied For *

Date of Application *

Last Name *

First Name *

Middle Name *

Street Address *

City *

State *

Zip Code *

Phone Number *

Best time to contact you at home is: *

If you are under 18 years of age, can you provide required proof of your eligibility to work?

Yes

No

Have you ever filed an application with us before?

Yes

No

If Yes, give date

Have you ever been employed with us before?

Yes

No

If Yes, give date

Do any of your friends or relatives, other than spouse, work here?

Yes

No

Are you currently employed?

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. Proof of citizenship or immigration status will be required upon employment.

Yes

No

Date available for work *

What is your desired salary range? *

Yes

No

Can you travel if a job requires it?

Yes

No

Have you been convicted of a felony within the last five years?

Yes

No

EDUCATION

Name of Elementary School

Name & Address of High School *

Diploma/Degree

Yes

No

Undergraduate College & Address *

Diploma/Degree

Yes

No

Graduate Professional College & Address *

Diploma/Degree

Yes

No

Describe any specialized training, apprenticeship, skills and extra-curricular activities.

Describe any job-related training received in the United States military.

EMPLOYMENT EXPERIENCE

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

List professional, trade, business or civic activities and offices held. You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status.

Employer 1 *

Employer Address 1

Employer 1 Phone Number

Job Title 1

Supervisor 1

Reason For Leaving

Start Date1

End Date1

Hourly Rate/Salary Starting

Hourly Rate/Salary Ending

Work Performed

Employer 2 *

Employer Address 2

Employer 2 Phone Number

Job Title 2

Supervisor 2

Reason For Leaving

Start Date2

End Date2

Hourly Rate/Salary Starting

Hourly Rate/Salary Ending

Work Performed

Employer 3 *

Employer Address 3

Employer 3 Phone Number

Job Title 3

Supervisor 3

Reason For Leaving

Start Date3

End Date3

Hourly Rate/Salary Starting

Hourly Rate/Salary Ending

Work Performed

ADDITIONAL INFORMATION

Summarize special job-related skills and qualifications acquired from employment or other experience.

State any additional information you feel may be helpful to us in considering your application

Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Can you perform the essential functions of the job, for which you are applying, either with or without a reasonable accomodation?

Yes

No

REFERENCES

Reference Name

Reference Address

Reference Phone

Reference Name

Reference Address

Reference Phone

Reference Name

Reference Address

Reference Phone

APPLICANT'S STATEMENT

I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

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.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledge in writing by an authorized executive of this organization.

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.

Name Of Applicant *

Date *

Whatley Health Services, Inc.

"MANAGING QUALITY PREVENTIVE HEALTH CARE"

2731 M.L. KING, JR. BLVD ~ P.O. BOX 2400 ~ TUSCALOOSA, AL 35403 (205)349-3250

Maude L. Whatley Health Center WHS at Oakman West Blocton Health Center James O. Ellis Health Center

Crescent East Health Center WHS at Sipsey Hale County Health Center Vernon Health Center

Tuscaloosa County Jail Clinic WHS at Eutaw Sumter County Health Center Mobile Health Unit

ADDENDUM TO EMPLOYMENT APPLICATION

"The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age, "or by other means. There term employment application," refers to all written inquires about employment or applications for employment or promotion including, but not limited to, resumes or other summaries of the applicant's background. It relates not only to written pre-employment inquiries, but to inquiries by employees concerning terms, conditions, or privileges of employment as specified in section 4 of the Act."

Please provide date of birth: *

A "yes" response may not prevent you from being offered a job for certain positions. If you answered "yes" to the following question, attach an explanation on a separate sheet of paper.

Have you ever been convicted of a law violation other than a minor traffic violation?

Yes

No

Name *

Date *