Employment Application

• 445 Biltmore Ave., Ste. 501 Asheville, NC 28801 • Fax: (828)254-4102 •

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Sisters Of Mercy Services Corporation

Application for Employment

* = required

Date:

First Name:

Middle Name:

Last Name*:

Current Address*:

City*:

State*:

Zip Code*:

Telephone #*:

E-Mail Address*:

Are you at least 18 years of age?* Yes: No:

If hired, can you present evidence of U.S. citizenshipor your legal right to live and work in this country?* Yes: No:

How were you referred to this company for employment?

Position Applied For:

Preferred starting date:

Salary desired:

Are you available for work shifts which may include evening and/or weekend hours? Yes: No:

Are you currently employed?* Yes: No:

If yes, may we inquire of your present employer?* Yes: No:

Have you applied to work for this company before? Yes: No:

If so, when?

Have you ever been convicted of a felony?* Yes: No:

Please note that criminal convictions are not an absolute bar to employment but will be
considered only with respect to the specific requirements of the position for which you are applying.

Education

Name of high school or equivalent program attended:

High School Location:

Did you graduate? Yes: No:

Name of college or technical school attended:

College or Technical Location:

Did you graduate? Yes: No:

Degree or certification obtained:

Are you currently licensed or
professionally registered in North Carolina?* Yes: No:

Other state(s)?* Yes: No:

Has your license, registration, or certification
ever been suspended, revoked, or voluntarily surrendered?*Yes: No:

Employment History

1. Employer name*:			Telephone #*:
Employer address*:			Position held*:
Employment dates*:	From:	To:	Ending salary*:
Reason for leaving:

2. Employer name*:			Telephone #*:
Employer address*:			Position held*:
Employment dates*:	From:	To:	Ending salary*:
Reason for leaving*:

3. Employer name:			Telephone #:
Employer address:			Position held:
Employment dates:	From:	To:	Ending salary:
Reason for leaving:

References (Please provide a minimum of two.)

1.Name *:	Telephone #*:
Address*:	Relationship*:

2. Name*:	Telephone #*:
Address*:	Relationship*:

3. Name:	Telephone #:
Address:	Relationship:

4. Name:	Telephone #:
Address:	Relationship:

The security and confidentiality of your personal health information are important to us.
Our e-mail is not encrypted and, thus, could be viewed by other parties during transmission.
Therefore, we ask that you do not send personally identifiable health information to us via e-mail.