Lexington Memorial Hospital250 Hospital Drive, Lexington, NC336.248.5191

Online application
Last Name:
 First Name:
 Middle Name:
Address:
City:
 State:
Zip:
 Country:
Home Phone:
 Work Phone:
Email address:

GENERAL INFORMATION
Position # applying for:
 
Department of interest:
Position applied for:
Date available for work:
Employment Status:
Shift preferred:
Any other shift:
Salary Expected: $
What source prompted you to apply with Lexington Memorial Hospital?
Have you ever made an application for employment with Lexington Memorial?
Yes No If yes, when?
Have you ever been employed with any company of Lexington Memorial?
Yes No If yes, company and when?

CRIMINAL RECORD
Have you ever been convicted of a crime (misdemeanor or felony) other that a minor traffic violation?  A conviction includes a plea, verdict, or finding of guilt regardless of whether sentence is imposed by the court.
Yes No If Yes, please explain
(Where)

(When)
 (Charged)

(Sentence)
(Disclosure of a criminal record will not necessarily disqualify you for employment.  Each conviction or guilty plea will be evaluated on its own merits with respect to time, circumstances and seriousness, in relation to the job for which you are applying.  However, failure to disclose such information may result in disqualification on your application or termination of employment.)
Describe any pending violations (excluding traffic violations):

EMPLOYMENT HISTORY
NOTE: Please give accurate, complete full-time and part-time employment record.  REMEMBER, EVERY SECTION OF THE EMPLOYMENT HISTORY MUST BE COMPLETED.
Begin with present or most recent employer
(including military service) 		Name, Title & Phone# of Supervisor
Present or Most Recent Employer
(if not presently employed, enter 'unemp') :
City, State
Employed from
to
Rate of pay $
to
Name:
Title:
Phone#:
Your Job Title & Responsibilities
Reason for leaving:
Past Employer:
City, State
Employed from
to
Rate of pay $
to
Name:
Title:
Phone#:
Your Job Title & Responsibilities
Reason for leaving:
Past Employer
(if no prior work history, enter 'none'):
City, State
Employed from
to
Rate of pay $
to
Name:
Title:
Phone#:
Your Job Title & Responsibilities
Reason for leaving:
Past Employer:
City, State
Employed from
to
Rate of pay $
to
Name:
Title:
Phone#:
Your Job Title & Responsibilities
Reason for leaving:

PROFESSIONAL OR TECHNICAL SPECIALTY

CERTIFICATION

Professional or Technical Specialty
 Year and State of First Certification or License
State
 License/Certificate #
Renewal No.
Expiration Date
N.C. License Applied For
Yes No
Do you have a valid driver's license ? Yes No State Number

EDUCATION & SKILLS

School Name & Address of School Attended Year
Began 		Year
Left 		Did You
Graduate 		Are You
Currently
Enrolled 		Major Subject
High School   Yes No Yes No
Technical School Yes No Yes No
College Yes No Yes No
Graduate School Yes No Yes No
Other / GED Yes No Yes No
 
List office machines you can operate:
Software brands used:
Other skills or special training experience:
List other skills, if any, relating to following clerical functions:
Typing Speed wpm, Dictaphone: Yes No, Word Processing: Yes No
Personal computer: Yes No, Medical Terminology: Yes No

FOREIGN LANGUAGE

Do you know a foreign language?
Yes No 		Read:  
Speak:
Write: 

MILITARY

COMPLETE THIS SECTION IF YOU SERVED IN THE U.S. ARMED FORCES
Describe your duties and any special training

 
Branch of service

 
Were you honorably discharged? Yes No
Period of active duty
From To
Rank at discharge

Date of final discharge

REFERENCES

Student or Recent Graduate: Give Clinical References Only.
Other Applications: List Personal References. (May Be Co-Workers)
Name School City & Address Telephone
(Optional) Paste resume:


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