Application for Employment - CareSouth of Carolina

CareSouth Carolina, Inc. APPLICATION FOR EMPLOYMENT
P.O. Box 1090, Hartsville, SC 29551
843-857-0111 (PLEASE PRINT) Date:
LAST NAME FIRST NAME MIDDLE
ADDRESS: STREET CITY STATE ZIP CODE
TELEPHONE NUMBER(S) SOCIAL SECURITY NUMBER
POSITION(S) APPLIED FOR: ________________________________________________________________________________________________
HOW DID YOU LEARN ABOUT US? ADVERTISEMENT, FRIEND, WALK-IN, RELATIVE, ❒EMP AGENCY, OTHER ___________
If you are under 18 years of age, can you provide required proof of your eligibility to work? Yes No N/A
Have you ever filed an application with us before? Yes No If yes, give date ____________________________
Have you ever been employed with us before? Yes No If yes, give date ____________________________
Are you currently employed? Yes No May we contact your current employer? Yes No
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status? Yes No
(Proof of citizenship or immigration status will be required upon employment.)
On what date would you be available for work? ______________________ FT PT Temporary (PRN)
Can you travel if a job requires it? Yes No Are you currently on “lay-off” status and subject to recall? Yes No
Have you been convicted of a felony within the last 7 years? Yes No (Conviction will not necessarily disqualify you from employment.)
If yes, please explain: _______________________________________________________________________________________________
EDUCATION
Name and Address of School Course of Study Years Completed Diploma/ Degree
Elementary
School
High
School
College or
Technical School
Graduate/
Professional
Describe any specialized training, apprenticeship, skills and extra-curricular activities that would enhance your qualifications.
We consider applicants for all positions without regard to race, religion, color, creed, gender, national origin, age, disability, marital or veteran status, or
other legally protected status.
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