PHSNC Employment Application

PHSNC Employment Application

It is the policy of Phila Health Systems of NC to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, national origin, age, disability or veteran status.
Name*

First NameLast Name
What area are you applying to?

Central - Cabarrus, Rowan, Gaston, Stanley, MecklenburgEast - Scotland, Richmond, Anson, HokeWest - Buncombe, AshevilleNortheast - Wayne, Durham, OrangeCoastal - WilmingtonProject R.E.D. Intern program
Last 4 of SSN*
Phone Number*
Please enter a valid phone number.
Driver's License Number*
STATE*
Email*
example@example.com
Availability to Start*

MonthDayYear
Date
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you able to provide proof that you are legally eligible for employment in the United States?*

YesNo
Current Employment

Name of Employer

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Employment*

Name of Employer

Street Address Line 2

CityState / Province

Postal / Zip Code
General Education *

High School or Equivalent

Street Address

CityState / Province

Postal / Zip Code
Advanced Education

Bachelor's, Masters, Doctorate

Street Address

CityState / Province

Postal / Zip Code

Professional Reference 1*

Street Address

Email Address

First and Last NameCurrent Job Title

Years Known / Company worked
Reference 2*

Street Address

Email Address

First and Last NameCurrent Job Title

Years Known / Company worked
Reference 3*

Street Address

Email Address

First and Last NameCurrent Job Title

Years Known / Company worked
Applicant Certification and Authorization I certify that the information provided in this application is truthful and accurate to the best of my knowledge. I understand that providing false or misleading information may result in the rejection of my application or, if employed, immediate termination of my employment. I authorize Phila Health Systems of NC to contact my previous employers and educational institutions to verify my employment history and academic records. I further authorize my former employers and educational organizations to fully and freely disclose information regarding my previous employment, attendance, and academic performance. Additionally, I grant permission for the individuals designated as references to provide relevant information about my work history and qualifications. If I am offered employment, I understand that, unless a specific written contract is signed by the CEO of Phila Health Systems of NC, my employment will be "at-will." This means that the employment relationship is voluntary for both myself and Phila Health Sysytems of NC, and either party may terminate the relationship at any time, with or without cause. I acknowledge that I may resign from my position at my discretion, by submitting a resignation letter to the Exexcutive adminstrater and my employer reserves the same right to end the employment relationship. Furthermore, I understand that no agent, representative, or employee of Phila Health Systems of NC—except through a specific written contract of employment signed by the CEO—has the authority to alter or modify the at-will nature of my employment. By signing below, I acknowledge that I have read, understand, and agree to the terms outlined in this certification.
Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Should be Empty: