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Application for Employment
Applications of all qualified applicants will be forwarded to the appropriate Department Director. The Department Director is responsible for reviewing applications and determining which applicants are qualified to be selected for interview. The Human Resources Department will notify all applicants that were interviewed when the position has been filled. Information regarding all open positions is available by calling the Jobline 828-326-3360. To update an application please call 828-326-2051. Thank you for your interest in Catawba Valley Medical Center.

PLEASE READ CAREFULLY BEFORE COMPLETING APPLICATION
We have committed ourselves to the recruitment, employment, training and promotion of employees solely on the basis of the individuals' qualifications and consider applicants for all positions without regard to race, color, religion, sex, age, national origin, marital or veteran status, the presence of any physical or mental medical condition or disability, or any other legally protected status in compliance with Federal or State Equal Opportunity Employment laws.
Required fields are marked with an "*".

PERSONAL INFORMATION
Date of Application (MM/DD/YYYY)* 
 Social Security # 
Last Name* 
 First Name* 
Middle Name 
 Maiden Name (if applicable) 
List all names you have used: 

Current Address *
 Permanent Address *
(if the Same, Please type "SAME")
Home Phone  * Work Phone  *
Other Phone     Fax Number    


Email Address * 


Are you over the age of 18?   
Please Select (Yes or No): *

Have you ever been convicted of, pleaded guilty or no contest, or paid a fine for any criminal offense? (This includes, but is not limited to felonies, misdemeanors, DWI, hunting offense, domestic violence, city or county ordinances. The only matters you should not disclose are minor traffic violations that did not involve alcohol.)

Please Select (Yes or No): *

If yes, explain for each conviction or plea, nature of offense, city, county, state of offense, date(s) of conviction, sentence and type(s) of rehabilitation, if any. (Note: pleading guilty, "no contest", or being convicted of an offense will not automatically disqualify you from consideration.)

Have you ever been declared ineligible from practicing in the Medicare, Medicaid, state or federal health care programs for reasons bearing on professional competency, performance or behavior?
Please Select (Yes or No): *

If yes, explain in detail.

EMPLOYMENT INTEREST
Position(s) that you are Applying for: (Choose at least one)
* (1)
    (2)
    (3)
Preferred status and shifts (hold Ctrl Key to choose multiple selections)
Status:
   		Shift:

Have you ever worked here before?      
Please Select (Yes or No): *

If yes, list dates of employment and name:

Were you referred by a CVMC employee?      
Please Select (Yes or No):

If yes, list name of employee:

How did you learn about Catawba Valley Medical Center?
When would you be available for employment?
Are you legally authorized to work in the United States?      
Please Select (Yes or No):

Are you currently employed?      
Please Select (Yes or No):

EMPLOYMENT RECORD
List all work experience. Begin with present or most recent employment, including self-employment.
Resumes cannot be substitued for this section.

(1) Present or Most Recent Employer: * 

Position: *  Employment Dates: * 
Address: * Specific Duties: *
Supervisor's Name and Title:  *
Supervisor's Telephone Number:  *
Pay Rate:  * $  (per hour, per week or per year): *
Reason for Leaving:  *

(2) Employer: 

Position:  Employment Dates: 
Address: Specific Duties:
Supervisor's Name and Title: 
Supervisor's Telephone Number: 
Pay Rate: $   (per hour, per week or per year):
Reason for Leaving: 

(3) Employer: 

Position:  Employment Dates: 
Address: Specific Duties:
Supervisor's Name and Title: 
Supervisor's Telephone Number: 
Pay Rate:  $  (per hour, per week or per year):
Reason for Leaving: 

(4) Employer: 

Position:  Employment Dates: 
Address: Specific Duties:
Supervisor's Name and Title: 
Supervisor's Telephone Number: 
Pay Rate:  $  (per hour, per week or per year):
Reason for Leaving: 

EDUCATION
High School or Equivalent (GED): 
Please Select (Yes or No):

       Location: 
Are you currently enrolled?      
Please Select (Yes or No):

Technical School:      Location: 


Are you currently enrolled?      
Please Select (Yes or No):

What Degree / Diploma did you earn? 
What was your area of study? 
College / University:      Location: 


Are you currently enrolled?      
Please Select (Yes or No):

What Degree / Diploma did you earn? 
What was your area of study? 
Please Select (Undergraduate or Graduate):

College / University:      Location: 


Are you currently enrolled?      
Please Select (Yes or No):

What Degree / Diploma did you earn? 
What was your area of study? 
Other Training / Education:    Location: 


Are you currently enrolled?      
Please Select (Yes or No):

What Degree / Diploma did you earn? 
What was your area of study? 
SPECIAL TRAINING OR SKILLS
Describe all special training, skills, professional courses or seminars:
  Are you Bi-Lingual?                                                 Hold the Ctrl Key to select all that apply:
 Please Select (Yes or No):

Please list language(s):    

Your Skills (Hold down the Ctrl Key to select all that apply):
 
List Computer System/Software: 
 List Office Equipment (dicatating equipment, etc): 
Comments: 
MILITARY STATUS
Branch: 
 Dates of Service : 
From: To:
Military Duties: 
    Special Training: 
   
PROFESSIONAL LICENSURE AND/OR CERTIFICATIONS
Training Institution: 
Year Graduated:  License Number: 
Renewal Number:  Expiration Date: 
List professional licenses / certifications / registrations: 

Are you registered in NC?
Please Select (Yes or No): 		If no, what state(s)?
Have you ever had your professional license revoked, suspended, surrendered or otherwise lost for reasons bearing on professional performance, professional competence or financial integrity? 
Please Select (Yes or No):

PERSONAL REFERENCES
Please list two persons that have known you for some time who can provide a personal reference. Do not include former employers or relatives.
(1) Reference Name:  *
Address:  *
Telephone Number:  *

(2) Reference Name:  *
Address:  *
Telephone Number:  *

If any of your family is employed here, who is it? 
In which Department: 
IN AN EMERGENCY NOTIFY
Name:  *     Relationship:  *
Address:  *     Home Phone:  *

    Work Phone: 

ADDITIONAL INFORMATION

Please list any other information you feel is pertinent to your application.

READ CAREFULLY BEFORE SIGNING
  • I certify that all answers and statements on this application are true and complete. I understand that any falsification, omission, or misrepresentation of facts in this application, in connection with my pre-employment physical examination or in connection with any aspect of the hiring process, will be cause for either the rejection of this application or for my discharge if I have been hired.
  • I understand that my employment will be contingent upon my passing a physical examination administered by Catawba Valley Medical Center's designated nurse or physician. I also understand that future examinations may be required by Catawba Valley Medical Center. I am aware that Catawba Valley Medical Center requires screening for drugs and alcohol as part of its pre-employment testing and that I may be required to take future examinations.
  • I authorize Catawba Valley Medical Center to make any inquiry or investigation deemed necessary to consider my employment application. This may include contacting former employers and a criminal record check. I understand that conviction of a crime will not automatically bar my employment. I may still be eligible for employment if Catawba Valley Medical Center determines my conviction could have no bearing to the job for which I am applying.
  • I authorize former employers and schools to release all information Catawba Valley Medical Center requests from them concerning my academic records, job performance, attendance, personal evaluations, or other related information. I release from liability and/or damages all parties which may give information regarding my application.
  • If my employment with Catawba Valley Medical Center terminates for any reason, I authorize Catawba Valley Medical Center to release all information and to answer any inquiries regarding my employment, performance, and the reasons for my termination.
  • I understand that if I am employed my employment will be strictly "at will". This means that my employment can be terminated at any time by me or by Catawba Valley Medical Center for any or no reason with or without notice or intermediate pleasures. I further understand that no verbal statements or statements in any policy or procedure manual, employee handbook, or other document shall be construed to alter the "at will" nature of my employment. I also understand that the terms, policies, procedures, and rules of employment are subject to change at any time by Catawba Valley Medical Center.
  • Although I may be employed for a specific work schedule. I understand Catawba Valley Medical Center does not guarantee my work schedule and may alter it as necessary.
  • I understand this application is current only for ninety days. I will renew it after that time if I wish to be considered for employment after it expires.
I have read, understand and certify that all information is correct in my employment application and that I AGREE with the above statements in their entirety.

*  Type your name here to certify this document, then press SUBMIT.

Click Submit only once.
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