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Name: (First Middle Last) *

Phone: *

Email: *   Please ensure email accuracy as this is the ONLY means by which you will be contacted or can check on your application.  

Complete Address (include City State and Zip)*


Date of Birth:*

Please list all positions and shifts that you are interested in:*

What Transportation do you have to Work?*

Proof of Citizenship*

Are you on a Medical Restriction, currently on Workers Comp or Taking controlled medications?*

Do you know anyone that currently is employed here?*

Have you applied with this company before? If so, when? *

Do you have children in your care? If so, do you have childcare arrangements so that you can work?*

What is your Highest Level of Education, degree or certification, and where obtained?

Are you a Certified Nursing Assistant?*

Have you obtained an MT certification, 80 hour certificate or any other credential at another facility?*

If you are applying for a Med Tech, have you worked as a med tech in the last year? When and where was your last MT position?

Please list your Most recent or Current job, duties, wages and reason for leaving:

Please list the 2nd most recent job, duties, wages and reason for leaving:

Please list the 3rd most recent job, duties, wages and reason for leaving:

If now employed, why do you desire to change?

Wages Expected?*

Please list an Emergency contact:*

Please list 3 professional references, just names and phone numbers: *

The State of NC requires a criminal history screening. Do you have any Felonies, Drug Charges, Abuse/Neglect or any negative activity you would need to discuss at interview?*

This facility is a Drug-Free workplace. You will be asked to submit to a drug screen. Type YES that you understand you will be required to participate in the drug screen. *

Type your name in this field as an Electronic Signature that you have submitted all answers truthfully. Falsification of the application will lead to dismissal if hired. Your signature indicates you further understand that if you work any shifts but terminate for any reason before the first paycheck issue date, that your employment is determined to be casual labor paid at minimum wage and therefore not entered into the payroll system. *

Date of Application*

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