Middle Creek Medical Center

For More Information

4810 Bell Hill Road

Bessemer, AL 35022

(205)477-DRDR(3737)

info@middlecreekmedicalcenter.com

Apply to Middle Creek Medical Center

General Information

First Name

Middle Name

Last Name

Maiden Name

Date of Birth

Social Security Number

Street Address

(no P.O. Boxes)

City

State

Zip Code

Home/Cell Phone

Job Information

Position Applied For

Part Time or Full Time

Times Available to Work

List all qualifications, skills, certifications and licensing

Education

College 1:

College Name

City/State

Degree

Dates Attended

College 2:

College Name

City/State

Degree

Dates Attended

High School:

High School Name

City/State

Diploma: Yes No

GED: Yes No

Dates Attended

Diploma Type: General Advanced

Employment History:

Employer 1

Employer Name

Phone

Dates

Job Duties:

Why did you leave or why do you want to leave your current employer?:

Employer 2

Employer Name

Phone

Dates

Job Duties:

Why did you leave or why do you want to leave your current employer?:

Employer 3

Employer Name

Phone

Dates

Job Duties:

Why did you leave or why do you want to leave your current employer?:

Permission to Contact Employers

May we contact your former employers? Yes No

May we contact your current employer? Yes No

If no, why?

Background

Have you ever been convicted of a felony? Yes No

If so, when?

List the felony:

References

List 3 references that we may contact. (Name, Address, contact number) Please list if they are personal or professional:

Emergency Contact

Please list a contact person and number that can be reached in case of an emergency situation:

Terms and Conditions

I certify and declare under penalty of perjury under relevant state and federal law that the information contained in my employment application is complete, true and accurate. I acknowledge that falsification or omission of information may result in immediate dismissal or retraction of any offer of employment.