Name: (First Middle Last) *
Phone: * Entering a phone number indicates you are agreeable to receiving texts regarding employment from this company. Replying STOP will remove you from any Text Lists.
Email: * Please ensure email accuracy as this is one of the methods by which you will be contacted
or can check on your application. Please check your Spam/Junk mail folder for correspondence.
Complete Address (include City State and Zip)*
Please list all positions and shifts that you are interested in:*
What Transportation do you have to Work?*
Are you on a Medical Restriction, currently on Workers Comp, have filed Workers Comp at another location, or Taking controlled medications?*
Do you know anyone that currently is employed here? If YES, please name that person and how related.*
Have you applied or worked 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 yes, please indicate what certifications you have.*
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 note that if wages expected are more than 15% higher than our payscale, you will likely not receive any correspondence about open positions.
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 hours will be paid at a standard training rate of $8 per hour. This will be a standard paycheck through the payroll system, including tax deductions. If you do not fill out tax forms prior to separation, deduction will be standard at a Single/Zero designation for both Federal and State taxes. If you do not fill out a direct deposit authorization prior to separation, the check WILL BE MAILED to the address on this application, therefore PLEASE ensure your address is CORRECT on this application. *
