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Employment Application

Step 1 of 5

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Position Applying For:*
Department:*
Shift Desired:
Name:*
First Last
Date of Birth:*
MM slash DD slash YYYY
Address:*
Street Address Address Line 2 City State ZIP Code
County:*
Email:*
Phone:*
Emergency Contact:
First Last
Emergency Contact Phone:
Relationship to Emergency Contact:
Registration # for Nurses/Medtechs/CNA:
State of Registration for Nurses/Medtechs/CNA:
Are you currently under investigation for resident abuse, neglect, mistreatment of property, or have a finding entered against you into a State Nurses Aide Registry?*
- Yes
- No
Have you ever been convicted of a felony or a crime?*
- Yes
- No
If yes, please describe:*
Do you have any specialized training for the position for which you are applying?*
- Yes
- No
Where did you receive your training:*
Approximate date of employment:*
What was your reason for leaving?*
If hired, can you provide proof of age and citizenship?*
- Yes
- No
Are you a citizen of the United States?*
- Yes
- No
If no, are you authorized to work in the U.S.?*
- Yes
- No
Have you ever worked for this company?*
- Yes
- No
If yes, when?*
Have you lived in NC for 5 consecutive years?*
- Yes
- No
If no, please list last state lived:*
What prompted you to apply for this position?

Education Information
Name of high school:
Location of high school:
Number of years to complete high school:
Name of college:
Location of college:
Number of years to complete college:
College major or degree:
List any other school experience not previously listed. Examples: business or trade school, professional school, etc.

References (Not Relatives)
Must list three below.
Reference #1 Name:*
First Last
Reference #1 Address:*
Reference #1 Phone:*
Reference #1 Business
Reference #1 Years Known:
Reference #2 Name:*
First Last
Reference #2 Address:*
Reference #2 Phone:*
Reference #2 Business
Reference #2 Years Known:
Reference #3 Name:*
First Last
Reference #3 Address:*
Reference #3 Phone:*
Reference #3 Business
Reference #3 Years Known:

Employment History
List up to three past employers below.
Employer #1 Name:
Employer #1 Address:
Employer #1 exact title of your position:
Employer #1 rate of pay:
Employer #1 date start (MM/YYYY):
Employer #1 date end (MM/YYYY):
Employer #1 Supervisors Name:
Employer #1 Phone:
May we contact Employer #1?
- Yes
- No
Duties (Be Specific) of Employer #1:
Reason for leaving from Employer #1:
Employer #2 Name:
Employer #2 Address:
Employer #2 exact title of your position:
Employer #2 rate of pay:
Employer #2 date start (MM/YYYY):
Employer #2 date end (MM/YYYY):
Employer #2 Supervisors Name:
Employer #2 Phone:
May we contact Employer #2?
- Yes
- No
Duties (Be Specific) of Employer #2:
Reason for leaving from Employer #2:
Employer #3 Name:
Employer #3 Address:
Employer #3 exact title of your position:
Employer #3 rate of pay:
Employer #3 date start (MM/YYYY):
Employer #3 date end (MM/YYYY):
Employer #3 Supervisors Name:
Employer #3 Phone:
May we contact Employer #3?
- Yes
- No
Duties (Be Specific) of Employer #3:
Reason for leaving from Employer #3:

Agreement to terms:*
I understand that I will be given a criminal background check, drug screen and TB skin test.

I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts asked for is cause for dismissal. Conover Nursing & Rehabilitation Center cannot guarantee you or any employee continued employment for any definite period of time. You have the right to terminate your employment at any time. Conover Nursing & Rehabilitation Center retains the same right to terminate your employment with or without cause. YOU ARE ALL AT-WILL EMPLOYEES (THAT IS YOUR EMPLOYMENT MAY BE AT ANY TIME FOR ANY REASON NOT IN VIOLATION OF FEDERAL OR STATE LAW WITHOUT CONOVER NURSING & REHABILITATION CENTER HAVING TO SHOW “JUST CAUSE” FOR THE DISCHARGE).

I also agree, if employed, to abide by the policies established by Conover Nursing & Rehabilitation Center.

NOTE: In order to complete your application, you must fax (828-448-5188) or call in (828-695-8282) your Social Security Number.
- I Agree

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Contact

(828) 695-8282

920 4th Street Southwest
Conover, NC 28613

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