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PERSONAL DATA |
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Name:
First,
Middle and Last |
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Street: |
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City/State/Zip: |
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Email
address: |
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Phone
(home): |
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Phone
(cell): |
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Referred by: |
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We
conduct criminal background checks on candidates prior to hiring. Have
you ever been convicted of a crime?
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If
so, explain: |
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Have
you previously applied at MedCost, MedCost Benefit Services, NC Baptist
Hospital or Carolina Health Care Systems?
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If yes, when: |
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Have
you ever worked for MedCost, MedCost Benefit Services, NC Baptist Hospital
or Carolina Health Care Systems?
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If yes, when: |
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List names
and relationships of relatives working for MedCost, MedCost Benefit
Services, NC Baptist Hospital or Carolina Health Care Systems:
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EMPLOYMENT
DATA |
Date available to work: |
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I am looking for: |
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Are
you available to work over-time? |
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Pay rate desired: |
$
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What position or
type of work are you applying for? |
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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: |
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Address: |
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Title/description
of work and special skills: |
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Reason for leaving: |
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May we contact your employer? |
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Telephone
#:
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Supervisor's name and title: |
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Dates
worked
to
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Starting
Salary:
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Ending
Salary: |
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Previous
employer:
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Address:
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Title/description
of work and special skills:
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Reason
for leaving:
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May
we contact your employer?
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Telephone
#:
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Supervisor's
name and title:
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Dates
worked
to
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Starting
Salary:
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Ending
Salary: |
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Previous
employer:
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Address:
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Title/description
of work and special skills:
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Reason
for leaving:
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May
we contact your employer?
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Telephone
#:
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Supervisor's
name and title:
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Dates
worked
to
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Starting
Salary:
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Ending
Salary: |
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EDUCATIONAL
DATA |
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High School: |
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City & State: |
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Highest
Grade Completed:
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Did you Graduate?: |
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Field
of Study or Degree:
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College:
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City & State:
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Highest
Grade Completed:
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Did you
Graduate?: |
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Field
of Study or Degree:
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Business
or Trade School:
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City & State:
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Highest
Grade Completed:
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Did you
Graduate?: |
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Field
of Study or Degree:
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Other:
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City & State:
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Highest
Grade Completed:
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Did you
Graduate?: |
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REFERENCES (must have known at least 5 years) |
Name:
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Address:
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Job Title:
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Years Known:
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Telephone
#:
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Email:
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Name:
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Address:
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Job Title:
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Years Known:
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Telephone
#:
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Email:
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Name:
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Address:
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Job Title:
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Years Known:
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Telephone
#:
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Email:
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U.S.
MILITARY SERVICE |
Branch:
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Service
Dates:
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to
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Duties
performed:
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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.
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I
have read and understand the agreement:
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SKILLS
OR TRAINING |
Typing: |
wpm |
Data
Entry:
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kph |
10-Key:
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kph |
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COMPUTER
SOFTWARE |
Microsoft
Word:
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Microsoft
Excel:
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Microsoft
Powerpoint:
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Microsoft
Publisher:
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Computer Training Courses Completed: |
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Customer Service Training Sources: |
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Comments: |
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UPLOAD
YOUR RESUME |
Select
a File: |
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