Email Forms Manager

Employment Desired
We offer equal employment opportunities for all individuals without regard to race, color, religion, age, sex,national origin, status as a veteran or disability, applications remain active for 60 days.
* Indicates required information
First Name *
Middle Name
Last Name *
Maiden Name
Application Date *	(mm/dd/yyyy)
Street Address 1 *
Street Address 2
City *
State *
Zip *
Social Security Number *
Email Address *
Home Phone *
Phone Number for Message *
First Choice
Experience?	Yes No None
Second Choice
Experience? *	Yes No
Have you worked at Rutherford Hospital or Carolina Community Care before? *	Yes No
If Yes, State Date	(mm/dd/yyyy)
Have you worked for us before under another name? *	Yes No
If Yes, State Name
Will you accept part time work? *	Yes No
Shift you can work:	1st 2rd 3rd
Will you accept temporary work? *	Yes No
Hours you can work
Are you either a United States citizen or an alien who has the legal right to work in the job for which you are applying? *	Yes No
Have you served in the U.S. military? *	Yes No
Please list job-related skills or experience.
Personal
Are you over the age of eighteen? *	Yes No
Are you willing to take a drug test and physical examination at our expense upon a conditional offer of employment? *	Yes No
Have you ever been convicted for any offense other than minor traffic violations? *	Yes No
If yes, explain
Have you ever been involuntarily discharged from a job? *	Yes No
If yes, explain and give dates.
List any friends or relatives working for us:
List any experiences, skills, or qualifications which you feel would especially fit you for work with our organization:
List office machines you can use:
Typing Speed (WPM)
Shorthand Speed (WPM)
Education
Last Elementary School Name and Address
Elementary School Number of Years Attended
Last High School Name and Address
Last High School Number of Years Attended
Last High School Diploma or Degree
Jr. College,College, or University Name and Address
Jr. College,College, or University Academic Major
Jr. College,College, or University Number of Years Attended
Techincal or Vocational School Name and Address
Techincal or Vocational School Academic Major
Techincal or Vocational School Number of Years Attended
Techincal or Vocational School Diploma or Degree
Other details of experience or training, including information on adult education programs which have a direct bearing on the job which you are seeking? (School, Course, Diploma or Certificate, Date Completed)
References: Give name(s) of persons we may contact to verify your qualifications for this position.
Name
Occupation
Phone
Organization
Address
Name
Occupation
Phone
Organization
Address
Name
Occupation
Phone
Organziation
Address
Employment Record: Give a complete record of all employment starting with the most recent or present employer:
Employer
From	(mm/dd/yyyy)
To	(mm/dd/yyyy)
Address
City, State, Zip
Phone
Salary
Position
Supervisor
Reason for Leaving
Employer
From Date	(mm/dd/yyyy)
To Date	(mm/dd/yyyy)
Address
City, State, Zip
Phone
Salary
Position
Supervisor
Reason for Leaving
Employer
From Date	(mm/dd/yyyy)
To Date	(mm/dd/yyyy)
Address
City, State, Zip
Phone
Salary
Position
Supervisor
Reason for Leaving
Employer
From Date	(mm/dd/yyyy)
To Date	(mm/dd/yyyy)
Address
City, State, Zip
Phone
Salary
Position
Supervisor
Reason for leaving
May we contact the employers listed above? *	Yes No
If not, indicate which one(s) you do not wish us to contact.
Professional Licenses, Registrations, and/or Certifications
Type
State Issued
Date	(mm/dd/yyyy)
No.
Type
State Issued
Date	(mm/dd/yyyy)
No.
Type
State Issued
Date	(mm/dd/yyyy)
No.
Area of specialization or major interest
If your application is considered favorably, on what date will you be available for work?
Job applicant statement
I certify that the answers given by me to the foregoing questions and statements are true and correct in all respects, and I agree that if employed and it is found to be false in any way, that I may be subject to dismissal without notice.
I agree that my employer shall not be liable in any respect if my employment is terminated because of the falsity of statements, answers, or omissions made by me in this questionnaire.
I understand that if an offer of employment is made, it will be conditional based upon results of a drug screen and criminal background check.
Further, I understand that any employment is not for a stated period of time and may be terminated with or without cause, at any time, at the option of my employer.
I understand that this application will remain active for 60 days, and after that time, a new application will be necessary.
I authorize employers, companies, schools or persons named above to give any information regarding my employment, together with any information they may have regarding me whether or not it is in their records.
I hereby release said employers, companies, schools or persons from all liability for any damage, both legal and otherwise, for issuing this information.
Name *
Initials *
Date *	(mm/dd/yyyy)
Filling in the Name, Initials, and Date boxes shown above and pressing the Submit button below constitutes a digital signature.