• Bertie County Rural Health Association Employment Application

  • PLEASE NOTE: It is important that you complete all parts of the application. If your application is incomplete or does not clearly show the experience and/or training required, your application may not be accepted. If you have no information for a particular section, simply type N/A. Upon completion of this application, simply select the Submit button.

  • Name and Address

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Job Type*
  • Date available to begin*
     - -

  • Additional Information

  • Have you ever been employed by this organization in the past?*
  • I certify that I am a U.S. citizen, permanent resident, or a foreign national with authorization to work in the United States.*
  • Have you ever been convicted of, or entered a plea of guilty, no contest, or had a withheld judgment to a felony?*
  • Do you have a driver's license?*
  • Rows
  • Have you even been in the Armed Forces?*
  • Are you now a member of the National Guard?*

  • Work Experience

  • Please list ALL work experience beginning with your most recent job held. Attach additional sheets if necessary.
  • Format: (000) 000-0000.
  • May we contact this employer?*
  • Format: (000) 000-0000.
  • May we contact this employer?
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  • Work Experience (continued)

  • Start Date
     - -
  • End Date
     - -
  • Format: (000) 000-0000.
  • May we contact this employer?

  • References

  • Please include name, phone number, and circumstances of your acquaintance. Exclude relatives and former employers.
  • I certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that, should this application contain any false or misleading information, my application may be rejected or my employment with this company terminated.
  • Date*
     - -
  • In Consideration of this Application for Employment, I acknowledge that Bertie County Rural Health Association may request information regarding my character, general reputation, and mode of living.
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