Employment – Iredell Surgical Center

Our employees are our most valuable asset. We are dedicated to projecting a professional image and striving to be the best in all we do.

Our goal is to attract, engage and retain the highest quality healthcare professionals and to create an environment where team members feel respected and are supported in a manner that enables them to perform to their fullest potential. We treat our patients with dignity and caring, giving them the courtesy and gentleness they need. We are helpful, we listen, we communicate, we respond to patient needs. We honor and uphold confidentiality, are honest and ethical, keep our commitments, accept responsibility for our actions, and respect the rights of patients, families and each other. If you share our values, we invite you to investigate career opportunities and learn more about Iredell Surgical Center.

Current openings:

PRN RN
PRN Certified Surgical Technician

Please fill out and hit submit to send this form to us in a secure format.

Application for Employment

PERSONAL INFORMATION

Date

Social Security Number(Required)

xxxxxxxxx (no dashes or spaces)

Name

First Middle Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Years at This Address

Home Phone

Work Phone

Cell Phone

Referred By:

Are you 18 years of age or older?

Yes

Employment Desired

Position

Date You Can Start

Salary Desired

Are You Employed Now?

Yes

If So, May We Inquire of Your Present Employer?

Yes

Ever Applied to this Company Before

Yes

When?

EDUCATION

Name and Address of Grammar School

Did You Graduate?

Yes

Subjects Studied and Degree(s) Received

Name and Address of High School

Did You Graduate?

Yes

Subjects Studied and Degree(s) Received

Name and Address of College

Did You Graduate?

Yes

Subjects Studied and Degree(s) Received

Name and Address of Trade, Business or Correspondence

Did You Graduate?

Yes

Subjects Studied and Degree(s) Received

GENERAL INFORMATION

Subjects of Special Study or Research Work:

Job Related Skills (typing, insurance filing, venipuncture, other languages, etc.:

FORMER EMPLOYERS

(List below your last four employers, starting with the last one first)

Name and Address of Employer

Date (Month and year) From and To

Salary

Position

Reason for Leaving

2nd Latest Employer

Name and Address of Employer

Date (Month and year) From and To

Salary

Position

Reason for Leaving

3rd Latest Employer

Name and Address of Employer

Date (Month and year) From and To

Salary

Position

Reason for Leaving

4th Latest Employer

Name and Address of Employer

Date (Month and year) From and To

Salary

Position

Reason for Leaving

PROFESSIONAL REFERENCES

(Medical references preferred if possible)

#1 Name

First Last

#1 Email

#1 Phone

#2 Name

First Last

#2 Email

#2 Phone

#3 Name

First Last

#3 Email

#3 Phone

REGISTRATION / CERTIFICATION

Check Which Applies

LPN

Surgical Technician

Other

Check Which Applies

BCLS Certified

ACLS Certified

#1 State / Certificate Number

#1 Renewal Number / Expiration Date

#2 State / Certificate Number

#2 Renewal Number / Expiration Date

Are there any prior or current substance abuse problems?

Yes

Have you ever been convicted of a felony?

Yes

If “Yes” please explain in the box below.

Explanation from question above...

AUTHORIZATION

If you are to be hired by the company, you will be required to attest to your identity and employment eligibility, and to present documents confirming your identity and employment eligibility. You cannot be hired if you cannot comply with these requirements. I certify that the facts contained in this application (and resume, if attached) are true and complete to the best of my knowledge. I understand that any false statement, omission, or misrepresentation on this application is sufficient cause for refusal to hire, or dismissal if I have been employed, no matter when discovered by Iredell Surgical Center. I understand that any employment is conditioned on a background check. I authorize the Iredell Surgical Center to thoroughly investigate all statements in my application and resume, and I authorize all current and former employers and references named in this application and/or resume to provide Iredell Surgical Center with any relevant information regarding an employment decision. I release all such persons and the Iredell Surgical Center from any liability regarding the provision of such information. In consideration of such employment, I agree to conform to the rules, policies and procedures of the Iredell Surgical Center. I understand that my employment may be terminated at any time and for any reason at my option or at the Iredell Surgical Center’s option, with or without cause and without prior notice. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the Iredell Surgical Center unless made in writing. If I am offered employment, I agree to submit to a medical examination and drug test before starting work, and that my refusal to submit for such testing will eliminate me from further consideration for employment. I also agree to submit to these same tests at any time deemed appropriate by the Iredell Surgical Center and as permitted by law.

By Typing in Your Name, You are Digitally Agreeing to all the fields being accurate on this form.

Date