Employment Application – Modern Treatment Health Care Services

Application for Employment
Modern Treatment Healthcare Services

400 Main St. W. Suite 9, Valdese NC 28690
An Affirmative Action/Equal Opportunity Employer
PERSONAL INFORMATION
DATE OF APPLICATION

Month Day Year
Date
Name

First Name Middle Name Last Name
Social Security Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Alternate Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone

Area Code Phone Number
Mobile Number

Area Code Phone Number
Email
example@example.com
How did you learn about our company?
POSITION SOUGHT
Applying for

Full Time Part Time First Shift Second Shift Third Shift
Available Start Date

Month Day Year
Date
Desired Pay Range
Are you willing to work any day(s),shift(s), Including nights, or overtime as assigned?

Yes No
Are you currently employed?

Yes No
Have you ever worked with individuals who have Mental Illness, Intellectual/Developmental Disabilities?

Yes No
Have you ever been convicted of a criminal offense?

Yes No
Have you ever been convicted of a Felony?

Yes No
Misdemeanor?

Yes No
Are there any pending charges against you?

Yes No
If you answered yes to any of the above questions, provide details, including the nature of the crime, dates, and location the offense occurred. *(Record of charges or convictions do not necessarily disqualify applicants from consideration for employment).
I certify that I am a US Citizen, permanent resident, or a foreign national with authorization to work in the United States.

Yes No
Do you have a Drivers License?

Yes No
Drivers License #
Issued in what state?
Have you lived in the state of North Carolina for 5 consecutive years?

Yes No
If you answered No to the above question, please list the state(s) of residence during the past
EDUCATION

Education

	Name and Location	Graduate? – Degree?	Major / Subjects
High School
College or University
College or University
Graduate School
Specialized Training,Trade School, etc…
Other Education

Please list your areas of highest proficiency, special skills, Licenses, Certifications, or other items that may contribute to your abilities in performing the above mentioned position.
PREVIOUS EXPERIENCE

Please list, beginning with most recent
Dates Employed
Company Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Job notes, tasks performed and reason for leaving:
May we contact this employer?

Yes No
Phone Number
Dates Employed
Company Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Job notes, tasks performed and reason for leaving:
May we contact this employer?

Yes No
Phone Number
Dates Employed
Company Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Job notes, tasks performed and reason for leaving:
May we contact this employer?

Yes No
Phone Number
Military Information
Have you ever been in the Armed Forces?

Yes No
Service Branch
Date Entered

Month Day Year
Date
Date Discharged:

Month Day Year
Date
Are you now a member of the National Guard?

Yes No
Do you currently have obligations to the National Guard?

Yes No
I authorize the release to Modern Treatment Healthcare Services (and any of its licensed agents), information held by parties regarding my previous employment, criminal history record, military records, driving record and scholastic records and hereby release said persons, schools, companies, government agencies, court and law enforcement agencies and authorities, from any damage whatsoever for releasing this information.

I certify that all information I have provided on this application is true and accurate. I understand that misstatements, omissions, or false or misleading statements which I have provided on this application, my resume and/or in interview(s) shall constitute grounds for refusal to hire or immediate termination from employment.

I understand that the terms and conditions of employment may be changed at any time without notice by the company. In consideration of employment with Modern Treatment Healthcare Services, I agree to comply with all the policies, procedures and requirements of Modern Treatment Healthcare Services. I understand this application and/or any policy, manual, handbook, or other written document describing such items do not constitute a written contract at this time or in the future. I understand my employment would be at-will and that my employment could be terminated at any time by either party, with or without cause and with or without notice. Any modifications of the at-will employment relationship, oral or written, can only be accomplished by a written document signed by Modern Treatment Healthcare Services owner.

I have read and understand the above.
Date

Month Day Year
Date
This employment application is current for 60 days. If you have not heard from us and still wish to be considered for employment, it will be necessary for you to fill out a new application.
Please return this application with:

Official sealed copy of your transcripts from school.

Copy of Social Security Card

Copy of Driver’s License

Any Current licensure or trainings

2 References that we can Contact

Declaration Page from your Insurance Company (car insurance)
Should be Empty:

Application for Employment

Modern Treatment Healthcare Services

PREVIOUS EXPERIENCE