PERSONAL DATA   

Name:
First, Middle and Last
Street:
City/State/Zip:
Email address:
Phone (home):
 
Phone (cell):
 
Referred by:
 
   

We conduct criminal background checks on candidates prior to hiring. Have you ever been convicted of a crime?


If so, explain:

Have you previously applied at MedCost, MedCost Benefit Services, NC Baptist Hospital or Carolina Health Care Systems?


If yes, when:

Have you ever worked for MedCost, MedCost Benefit Services, NC Baptist Hospital or Carolina Health Care Systems?


If yes, when:

List names and relationships of relatives working for MedCost, MedCost Benefit Services, NC Baptist Hospital or Carolina Health Care Systems:

  
EMPLOYMENT DATA 
Date available to work:
I am looking for:


Are you available to work over-time?
Pay rate desired:
$
What position or type of work are you applying for?
  
WORK EXPERIENCE  
 List the last three positions you have held beginning with the most recent. Accuracy of dates and addresses are essential.
Present or last employer:
Address:
Title/description of work and special skills:
Reason for leaving:
May we contact your employer?
Telephone #:
Supervisor's name and title:
   Dates worked to
Starting Salary: Ending Salary:
  
Previous employer:
Address:
 
Title/description of work and special skills:
 
Reason for leaving:
 
May we contact your employer?


Telephone #:
Supervisor's name and title:
 
   Dates worked to
Starting Salary: Ending Salary:
 
Previous employer:
Address:
 
Title/description of work and special skills:
 
Reason for leaving:
 
May we contact your employer?


Telephone #:
Supervisor's name and title:
 
   Dates worked to
Starting Salary: Ending Salary:
 
EDUCATIONAL DATA   
High School:
City & State:
Highest Grade Completed:
 
Did you Graduate?:


Field of Study or Degree:
 
College:
City & State:
Highest Grade Completed:
Did you Graduate?:


Field of Study or Degree:
 
Business or Trade School:
City & State:
Highest Grade Completed:
Did you Graduate?:


Field of Study or Degree:
 
Other:
City & State:
Highest Grade Completed:
Did you Graduate?:


  
REFERENCES (must have known at least 5 years)  
Name:
Address:
 
Job Title:
 
Years Known:
Telephone #:
Email:
 
 
Name:
Address:
 
Job Title:
 
Years Known:
Telephone #:
Email:
 
 
Name:
Address:
 
Job Title:
 
Years Known:
Telephone #:
Email:
 
 
U.S. MILITARY SERVICE  
Branch:
Service Dates:
to
Duties performed:
 
 
APPLICANT'S CERTIFICATION AND AGREEMENT
The information that I have provided on this application is complete and accurate to the best of my knowledge and subject to validation by MedCost, LLC and its affiliates. I understand that any misleading or incorrect statements or omissions may result in my not being employed or if I am employed, may be cause for immediate dismissal at any time during my employment.

I authorize all persons, schools, employers and other organizations to provide MedCost with any relevant information that may be required to arrive at an employment decision. I hereby release these individuals, employers and NC Baptist Hospital and Carolina Health Care Systems from availability for any damage incurred in furnishing such information.

In processing the employment application, I understand that MedCost may request investigative Credit Bureau report, which may include information as to my character and general reputation. Per the Federal Fair Credit Reporting Act, I have the right to make a written request to the credit agency of its disclosure. I may also request, in writing, the company’s use of this report.

Employment with MedCost, LLC is contingent upon the successful completion of a drug-screening test to be administered after an offer of employment is made. Successful completion of the test means that the person tested negative for illegal drugs or substance abuse.

In consideration of my eventual employment with MedCost I agree to conform to the rules and regulations of the company. I understand that my employment, compensation and benefits can be terminated, with or without cause, and with or without notice, at any time, at the option of the company; likewise, I am free to resign at anytime.

I have read and understand the agreement:


 
SKILLS OR TRAINING  
Typing:
wpm
Data Entry:
kph
10-Key:
 kph
 
COMPUTER SOFTWARE  
Microsoft Word:


Microsoft Excel:


Microsoft Powerpoint:


Microsoft Publisher:


Computer Training Courses Completed:
Customer Service Training Sources:
Comments:
 
UPLOAD YOUR RESUME  
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