Current Open Position(s) for Which You Are Applying		Type of Position Per Diem Pool Full Time PRN Part Time Temporary		Shift   Weekend Day Night Evening Rotation
Salary Requirement		Are you willing to travel? Yes   No		Are you willing to relocate? Yes   No
Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours? Yes   No
If overtime work is required periodically, does this pose a problem for you? Yes   No		Date Available for work 123456789101112 / 12345678910111213141516171819202122232425262728293031 / 200820092010		Are You Legally Authorized to Work in the U.S.? Yes   No
Have you ever worked at this facility or in a facility associated with LifePoint Hospitals, or its affiliates? Yes   No		If yes, what facility?		Are you related to another facility employee? Yes   No

How did you learn about this position? State Employment Commission Agency Ad Job Listing School Current Employee Internet Other	Are you able to perform the essential, job related functions of the position for which you are applying with or without reasonable accommodations? Yes   No
	Have you been convicted of a crime and/or released from confinement following a conviction for any criminal offense? Yes   No (Conviction will not necessarily disqualify an applicant from employment.) If yes, give date, place and nature of each such conviction.
	Are you currently excluded from participation in any federally funded healthcare program - including Medicare and Medicaid - and/or are you aware of any potential exclusion from a federally funded health program? Yes   No

Educational History
Type of school	Name of School			Last Year of School	Degree or Certificate
	City, State
Highschool / GED				1    2    3    4 Graduated/GED Yes   No
College				1    2    3    4 Graduated Yes   No
College				1    2    3    4 Graduated Yes   No
Graduate School				1    2    3    4 Graduated Yes   No
Other				1    2    3    4 Length of time attended
Other				1    2    3    4 Length of time attended

List any proffessional licenses, registration, or certification you possess (Include Drivers License, if applicable) Type State Issued Exp Date Number Has your license(s) in this state or another state been suspended, limited, revoked or under investigation? Yes   No If yes, please explain

Clerical or other skills applicable to the position for which you are applying Typing ( WPM) PBX Proficient in Software: Business machines and/or equipment you can operate: Other:

Employment History Please provide a minimum of the most recent 10 years employment history including any period of unemployment. Attach additional pages if needed
Current or Most Recent
From 123456789101112 /20082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959 To 123456789101112 /20082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959	Company
	Phone			Immediate Supervisor
Salary	Address				Name while employed
May we contact them? Yes   No		Other reference with this employer
Job Title					Reason for Leaving
Nature of Duties
1st Previous
From 123456789101112 /20082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959 To 123456789101112 /20082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959	Company
	Phone			Immediate Supervisor
Salary	Address				Name while employed
May we contact them? Yes   No		Other reference with this employer
Job Title					Reason for Leaving
Nature of Duties
2nd Previous
From 123456789101112 /20082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959 To 123456789101112 /20082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959	Company
	Phone			Immediate Supervisor
Salary	Address				Name while employed
May we contact them? Yes   No		Other reference with this employer
Job Title					Reason for Leaving
Nature of Duties
3rd Previous
From 123456789101112 /20082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959 To 123456789101112 /20082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959	Company
	Phone			Immediate Supervisor
Salary	Address				Name while employed
May we contact them? Yes   No		Other reference with this employer
Job Title					Reason for Leaving
Nature of Duties

Professional References (other than Relatives) Give two references who have good knowledge of your work.
Name	Position	Address	Phone	Number of years known

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