McLean Cares Healthcare Group

Family Healthcare of SWGA, PC

(229)228-6577 Phone
(229) 228-4708 Fax (Attn. Jelani A. McLean, MPA)
Nu Image Weight Loss & Management Center
Thomasville
(229)228-6500 Phone
(229)228-6577 Phone
(229)228-4708 Fax (Attn. Jelani A. McLean, MPA)
Macon
(478)314-0890 Phone
(478)314-0894 Fax (Attn. Nini McLean)
Complete Care & Pain Management Institute, LLC
(478)314-0890 Phone
(478)314-0894 Fax (Attn. Nini McLean)
wecare4you@mclean-cares.com
DATE _________________________________

PLEASE COMPLETE PAGES 1-5.

Name _______________________________________________________________________________________________
Last

First

Middle

Maiden

Present address _______________________________________________________________________________________

Number

Street

City

Zip

Social Security No. _______ _____ _________

How long ____________________

Telephone (

State

Email Address: _________________________________

) ______________

Date of Birth __________________

If under 18, please list age _____________________
Days/hours available to work
No Pref _______ Thur _________
Mon _________ Fri __________
Tue __________ Sat __________
Wed _________ Sun _________

Position applied for (1) ________________________

and salary desired (2) ________________________
(Be specific)
How many hours can you work weekly? ________________________
Employment desired

FULL-TIME ONLY

PART-TIME ONLY

FULL- OR PART-TIME

When available for work? ______________

_____________________________________________________________________________________________________
Are you a US Citizen: Yes No

Gender: Male Female

TYPE OF SCHOOL

NAME OF SCHOOL

LOCATION
(Complete mailing
address)

NUMBER OF YEARS
COMPLETED

MAJOR &
DEGREE

High School
College
Bus. or Trade School
Professional School

HAVE YOU EVER BEEN CONVICTED OF A CRIME?

No

Yes

If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were
committed, sentence(s) imposed, and type(s) of rehabilitation. ___________________________________________________
_____________________________________________________________________________________________________

INTER- OFFICE
ONLY
Is Application Complete?
Yes

Other _______________________________

No

Completed Application Includes:

Non-Pay to Provider Form (DHS-4611-ENG) Yes No
Individual PCA Form (DHS-4469-ENG) Yes No

Please list two references other than relatives or previous employers.

Name ________________________________________

Name ____________________________________________

Position ______________________________________

Position ___________________________________________

Company _____________________________________

Company _________________________________________

Address ______________________________________

Address ___________________________________________

______________________________________

__________________________________________

Telephone (

Telephone (

An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the
space below to summarize any additional information necessary to describe your full qualifications for the specific position for
which you are applying.

Work
Experience

Please list your work experience for the past five years beginning with your most recent job held.
If you were self-employed, give firm name. Attach additional sheets if necessary.

Name of employer
Address
City, State, Zip Code
Phone number

Name of last
supervisor

Employment dates

Pay or salary

From

Start

To

Final

Your last job title

Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.

Name of employer
Address
City, State, Zip Code
Phone number

Name of last
supervisor

Employment dates

Pay or salary

From

Start

To

Final

Your Last Job Title

Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.

Work
experience

Please list your work experience for the past five years beginning with your most recent job held.
If you were self-employed, give firm name. Attach additional sheets if necessary.

Name of employer
Address
City, State, Zip Code
Phone number

Name of last
supervisor

Employment dates

Pay or salary

From

Start

To

Final

Your last job title

Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.

Name of employer
Address
City, State, Zip Code
Phone number

Name of last
supervisor

Employment dates

Pay or salary

From

Start

To

Final

Your last job title

Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.

May we contact your present employer?

Yes

No

Signature of applicant__________________________________________ Date: ___________________

This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions
without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you
that your opportunity for employment with this Company depends solely on your qualifications.

Thank you for completing this application form and for your interest in our business.

Questionnaire
1. Why do you want to work for Family Healthcare?
_____________________________________________________________________
_________________________________________________
2. What can you offer the company?
_____________________________________________________________________
_________________________________________________
3. Describe how important would loyalty and honesty play a role to you
for this company?
_____________________________________________________________________
_________________________________________________
4. Do you think that you are a good leader or a good follower? Why?
_____________________________________________________________________
_________________________________________________
5. Are you comfortable taking directions from other employees?
________________________________________________________________________
____________________________________________________
6. How important is your professionalism?
_____________________________________________________________________
_________________________________________________
7. In what manner will you handle conflict with colleagues or patients?
_____________________________________________________________________
_________________________________________________
8. Describe some of your good work habits?
_____________________________________________________________________
_________________________________________________
9. What are your salary or wage expectations? Why?
_____________________________________________________________________
_________________________________________________

Please fax completed application to the office that you are applying to.
You may also email this application to: wecare4you@mclean-cares.com