West Central Georgia Regional Hospital



West Central Georgia Regional Hospital

P. O. Box 12435

Columbus, GA 31917-2435

(706) 568-2260 – Tel.

(706) 568-5331 – Fax.

Employment of Relatives Policy #1204

For purposes of compliance with Policy #1204 of the GA Department of Human Resources, do you have any relatives currently employed with West Central Georgia Regional Hospital?

□Yes □ No

If yes, please list below.

Name Relationship Title Department

1. _______________ _______________ ______________ _________________

2. _______________ _______________ ______________ _________________

3. ________________ _______________ ______________ _________________

4. _______________ _______________ ______________ _________________

________________________________________ ________________

Signature of Applicant Date

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