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.

How Did You Learn About Us?
If you are under 18 years of age, can you provide required proof of your eligibility to work?
Have you ever filed an application with us before?
Have you ever been employed with us before?
Do any of your friends or relatives, other than spouse, work here?
Are you currently employed?
May we contact your present employer?
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.
Are you available to work:
Can you travel if a job requires it?
Have you been convicted of a felony within the last five years?

EDUCATION

Diploma/Degree
Diploma/Degree
Diploma/Degree

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.

ADDITIONAL INFORMATION

Specialized Skills (Check Skills/Equipment Operated)

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?

REFERENCES

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.

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

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."

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?

We provide quality health care to West Alabama.