Please fill out the form below.

Date
Social Security
Name
Address
City
State
Zip Code
Legal to work in the United States?	Yes  No
Phone Number
Position Applied For
Salary Desired
Ever Applied to SMA before?	Yes  No
If yes, when?
Would you prefer to work	Full time Part Time Temporary
Are you employed now?	Yes     No
May we contact your former employers?	Yes No
Former employers:
High School
Graduate?	Yes No
College
Course/Major
Graduate?	Yes    No
Nursing School
Credentials
Name of friend or relative employed by this orginization
Position held:
If eligible, are you interested in insurance?	Yes No
Emergency Contact
Relationship
Phone Number

ACKNOWLEDGEMENT (please read carefully)

I hereby certify that the information contained in this application form and in any attachments listed below (hereafter made a part of this application) is true and correct to the best of my knowledge and agree to have any of the statements checked by the organization unless I have indicated to the contrary. I authorize the references listed above to provide the company any and all information concerning my previous employment and any pertinent information that they may have. Further, I release all parties and persons from any and all liability for any damages that may result from the furnishing such information to the company as well as from the use or disclosure of such information by the organization or any of its agents, employees or representatives. I understand that any misrepresentation, falsification, or material omission of information on this application may result in my failure to receive an offer or, if I am hired, in my dismissal from employment.