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Floyd County Medical Center (FCMC) provides for a fair and equal employment opportunity for all job applicants regardless of race, color, religious creed, national origin, ancestry, age, gender, pregnancy, sexual orientation, gender identity, age, marital status, familial status, disability or genetic information, in compliance with applicable federal, state and local law. FCMC hires and promotes individuals solely on the basis of their qualifications for the job to be filled.

FCMC reasonably accommodates qualified individuals with disabilities to enable them to receive equal employment opportunity and/or perform the essential functions of the job, unless the accommodation would impose an undue hardship to FCMC. This applies to all applicants and employees.

FCMC also provides a work environment in which each employee is able to be productive and work to the best of his or her ability. We do not condone or tolerate an atmosphere of intimidation or harassment. We expect and require the cooperation of all employees in maintaining an atmosphere free from discrimination and harassment with mutual respect by and for all employees and applicants.

If for any reason you are unable to fill out this online form, please download the PDF version and submit to the address listed on the form.

Floyd County Medical Center is an E-Verify employer. E-Verify is a web-based system that allows enrolled employers to confirm the eligibility of their employees to work in the United States. E-Verify employers verify the identity and employment eligibility of newly hired employees by electronically matching information provided by employees on the Form I-9, Employment Eligibility Verification, against records available to the Social Security Administration (SSA) and the Department of Homeland Security (DHS).

For more information visit e-verify.gov. Click to see the Notice of E-Verify Participation poster in English and Spanish. Click to see the Right to work Poster in English or Spanish.

1Personal Information

2Employment Desired

3Education

4Employment History

5References

6Resume / Cover Letter

7Signature

Personal Information
Employee Date
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Employee Name*
First Middle Last
Address*
Street City State / Province / Region ZIP Country
Telephone (Area Code/Number)*
Email Address*
Are you 18 years of age or older?*
- Yes
- No
Are you legally eligible for employment in the U.S.?*
- Yes
- No
Do you have a record of founded child or dependent adult abuse or have you ever been convicted of a crime in this state or any other state?*
- Yes
- No
If 'Yes', please explain:*
What prompted you to apply at FCMC for employment?

By submitting this form, I certify the information contained in this application for employment is true to the best of my knowledge and belief. I understand that any omission of facts or misrepresentation is cause for denial of employment and/or dismissal (if hired) regardless of when discovered.

I give FCMC the right to contact and obtain information from all references, employers, educational institutions and to otherwise verify the accuracy of the information contained in this application including conviction records and dependent adult & child abuse records. I hereby release from liability the employer and its representatives for seeking, gathering, and using such information and all other persons, corporations or organizations for furnishing such information.

If I am hired, I understand that I am free to resign at any time, with or without cause and without proper notice, and FCMC reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no representative of the employer, other than an authorized officer, has the authority to make any reassurances to the contrary. I further understand that any such assurance must be in writing and signed by an authorized officer.

I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization. I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions.
Applicant Signature*
Date
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