We do not discriminate based on age over 40, race, sex, color, religion, national origin, disability, or any other applicable status protected by state or local law. It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors.

Each question should be fully and accurately answered. No action can be taken on this application until all questions have been answered. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal preferences or discrimination based upon non-job-related information.

Select Your Nearest Branch Location(Required)

Job Applied For(Required)

Are you seeking:(Required)

Full-time

Part-time

Temporary

When could you start work?

Name(Required)

First Middle Last

Telephone Number(Required)

Mobile Number

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Date of Birth(Required)

Social Security #

If hired, can you furnish proof you are eligible to work in the U.S.?

Yes

Have you ever applied here before?(Required)

Yes

If yes, when?

Were you ever employed here?(Required)

Yes

If yes, when?

Have you ever been convicted of any law violation (except a minor traffic violation)?(Required)

Yes

If yes, give details:

(A “Yes” answer does not automatically disqualify you from employment, since the nature of the offense, date, and the job for which you are applying will also be considered.)

Do you have a valid driver’s license?(Required)

Yes

Driver’s License Number

State of License

Class of License

Have you had your driver’s license suspended or revoked in the last 3 years?

Yes

If yes, give details:

List professional, trade, business or civic activities and offices held. (Exclude labor organizations and memberships which reveal age over 40, race, sex, color, religion, national origin, disability or other protected status.)

Please indicate the valid certifications and licenses that you have

Level of Education

High School or GED

# of Years Completed

Diploma/Degree/Certificate

Subjects Studied

College or University

# of Years Completed

Diploma/Degree/Certificate

Subjects Studied

Vocational or Technical

# of Years Completed

Diploma/Degree/Certificate

Subjects Studied

What skills or additional training do you have that are related to the job for which you are applying?

What machines or equipment can you operate that are related to the job for which you are applying?

Employment History

List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references. PLEASE GIVE MONTH AND YEAR.

1 — Name Of Employer

Job Title And Duties

Dates Of Employment

From

Address

Street Address City State ZIP Code

Reason For Leaving

2 — Name Of Employer

Job Title And Duties

From

Address

Street Address City State ZIP Code

Reason For Leaving

2 — Name Of Employer

Job Title And Duties

From

Address

Street Address City State ZIP Code

Reason For Leaving

Have you worked or attended school under any other name?

Yes

If yes, give names

Are you presently employed?

Yes

If yes, may we contact your present employer?

Yes

Have you ever been fired from a job or asked to resign?

Yes

If yes, please explain

Give three references, not relatives or former employers

Name

Address

Phone

Name

Address

Phone

Name

Address

Phone

PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING

I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.

I understand that the employer may request an investigative consumer report from a consumer reporting agency. This report may include information as to my character, reputation, personal characteristics and mode of living obtained from interviews with neighbors, friends, former employers, schools and others. I understand I have a right to make a written request within a reasonable time for the disclosure of the name and address of the consumer reporting agency so that I may obtain a complete disclosure of the nature and scope of the investigation.

I authorize the investigation of any of all statements contained in this application and also authorize any person, school, current employer (except as previously noted), past employers and organizations named in this application to provide relevant information and opinions that may be useful in making a hiring decision. I rel ease such persons and organization from any legal liability in making such statements. I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying.

I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre and/or post-employment drug screen as a condition of employment, if required.

I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITH NOTICE. I have read, understand, and by my signature consent to these statements

Please Type Your Name for Electronic Siganture(Required)

Date(Required)

This application for employment will remain active for a limited time. Ask the organization representative for details.

Telephone Reference Check Form - # 1

EMPLOYMENT INFORMATION: To be completed by Applicant

Name of first Professional Reference to Be Contacted

Title

Company Name

Phone

Reason for leaving this company:

I authorize the company I worked for and/or the individual listed above to release information about me to Supreme Health Systems, Inc.(Required)

I authorize

Please Type Your Name for Electronic Siganture(Required)

Date(Required)

Telephone Reference Check Form - # 2

EMPLOYMENT INFORMATION: To be completed by Applicant

Name of first Professional Reference to Be Contacted

Title

Company Name

Phone

Reason for leaving this company:

I authorize the company I worked for and/or the individual listed above to release information about me to Supreme Health Systems, Inc.(Required)

I authorize

Please Type Your Name for Electronic Siganture(Required)

Date(Required)

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Careers

Level of Education

Employment History

PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING

Telephone Reference Check Form - # 1

Telephone Reference Check Form - # 2

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Greensboro

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Salisbury

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