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NC Healthplus Employment Application
If you are interested in working for Healthplus Child & Family Services, please complete and submit the application below. Please send your resume via email; info@nchealthplus.com, or mail to address provided.

* = required
Position Applying For *
Location
Service *
First Name *
Last Name *
Address *
Address 2
City *
State *
Zip *
Phone *
Best time to contact you: *
Work Phone
May we contact you at work? Yes No
E-mail Address *


Are you over the age of 18? yes no*
Have you ever applied with us before? yes no
          If YES, give date(s):
Are you currently employed? yes no
Do you have any relatives who are current employees of Healthplus? yes no
Are you legally eligible to work in the United States? yes no*
Date available for work:
What shifts are you available to work?
Are you currently on "lay off" status and subject to recall? yes no
Will you work overtime if asked? yes no
Your current wage


Drivers License #: *
State Issued: *
Has your Drivers License ever been suspended or revoked? yes no
      If YES, explain:     
Have you been part of an auto accident in the past 3 years? yes no
      If YES, how many:
Have you had any moving violations during the past 3 years? yes no
      If YES, how many:
Have you ever been arrested or charged with a crime? yes no*
      If YES, explain in full:
Do you have any civil or criminal charges or traffic violations pending at this time? yes no
      If YES, explain in full:
A conviction record will not necessarily be a bar to employment.


Educational Information
Education *
Did you graduate? yes no*
Diploma/Degree(s)
GPA


Employment History

Please fill out the employment information for your two most recent jobs, beginning with the most recent.
Most Recent Employer
Address
Telephone
Employment Dates
Title
May We Contact Employer yes no
Duties and Responsibilities
 
Employer 2
Address
Telephone
Employment Dates
Title
May We Contact Employer yes no
Duties and Responsibilities
 
Employer 3
Address
Telephone
Employment Dates
Title
May We Contact Employer yes no
Duties and Responsibilities


Additional Information
Describe any childcare training, specialized training, apprenticeship, skills and extracurricular activities (i.e. First Aid, CPR, NCI etc.)
Additional Information: Include other pertinent information to describe your qualifications.
How did you learn about Healthplus Child & Family Services?
Questions or Comments

Healthplus Therapeutic Services | 233 East Seventh Street | Washington, NC 27889 | Phone: 252.948.0333 | Fax: 252.948.0933