Name / Primary Phone
Street / City, State, Zip
Date of Birth / Social Security #
Alternate Phone / Driver’s License #
Email: / Alt: Email
Preferred Method of Contact : ☐Email ☐Phone/Text
Employment Desired ( Check All that Apply)
☐ / Full Time / ☐ / Contract
☐ / Part-Time / ☐ / PRN (As Needed)
Earliest Date available to Begin Work / Salary Desired
Education (Please include High School, College, Graduate)
Name of Schools Attended / Location (City, State) / Dates Attended / Degree Received
Special Training or Volunteer Work received in the area of employment
Have you ever been convicted of a Felony?☐Yes ☐No If yes please explain
Have you lived outside the state of NC in the past 5 years☐Yes ☐No
If yes where:______
Employment HistoryCompany Name
Contact Name / Phone
Employed From/To / Salary Paid
Position Held / Last Worked
Please Describe Job Duties Below:
Company Name
Contact Name / Phone
Employed From/To / Salary Paid
Position Held / Last Worked
Please Describe Job Duties Below:
Company Name
Contact Name / Phone
Employed From/To / Salary Paid
Position Held / Last Worked
Please Describe Job Duties Below:
Employment History
Company Name
Contact Name / Phone
Employed From/To / Salary Paid
Position Held / Last Worked
Company Name
Contact Name / Phone
Employed From/To / Salary Paid
Position Held / Last Worked
Company Name
Contact Name / Phone
Employed From/To / Salary Paid
Position Held / Last Worked
References Please Include Two Personal & Two Business
Name / Primary Phone
Street / City, State, Zip
Relationship / Years Known
Personal/Business / Email
Preferred Method of Contact : ☐Email ☐Phone/Text
Name / Primary Phone
Street / City, State, Zip
Relationship / Years Known
Personal/Business / Email
Preferred Method of Contact : ☐Email ☐Phone/Text
Name / Primary Phone
Street / City, State, Zip
Relationship / Years Known
Personal/Business / Email
Preferred Method of Contact : ☐Email ☐Phone/Text
Name / Primary Phone
Street / City, State, Zip
Relationship / Years Known
Personal/Business / Email
Preferred Method of Contact : ☐Email ☐Phone/Text
At The M.E. Green House we not only promote growth in our consumers, but in our staff as well. Please use the space below to discuss your interest and career goals.
In the space below please list any professional organizations in which you are a member or that you are interested. (Please specify membership/non membership)
At the Green House we promote strength and growth. Please use the space below to discuss your strengths as a prospective team member. (What do you do well?)
The M.E. Green House, is an Equal Opportunity Employer and selects employees based on merit, qualifications, and abilities. MEGH does not discriminate in employment opportunities or practices on the basis of race, color, religion, gender, marital status, national origin, age, physical or mental handicap, or status as a Vietnam era or special disabled veteran, or any other characteristic protected by law.
1)I understand and agree that any material misrepresentation or omission of fact in my
application will render this application void and may result in refusal to employ me or, if hired, termination of my employment.
2)I authorize MEGH to investigate my work history, to verify all data given in my application for
employment, related documents, or interviews, and to contact my former employers, references, reporting agencies, and any other persons. I recognize and acknowledge that any such information may be the basis for declining the employment applied for or, if hired, for terminating the employment. Irequest and authorize all persons so contacted to furnish the information so requested and, in consideration for so doing, hereby release any persons furnishing or receiving such information from all liability which might arise out of the communication so made or the information so furnished.
3)I agree that, if given a conditional offer of employment, I will provide, and authorize any
physician or hospital to release, any information which may be necessary to determining my ability to perform the duties of the job for which I have been offered employment.
4)I agree to take a medical examination by a qualified physician at the discretion of
MEGH, after a conditional offer of employment has been made by MEGH.
5)I understand and agree that any employment offered pursuant to this application will be at-
will, terminable by either party at any time with or without reason with or without notice, and with or without procedural formality or progressive discipline. I understand and agree that no representation, written or oral, express or implied, including without limitation those contained in any employment manuals, handbooks or information booklet that may be distributed to me during the course of my employment, shall form-a contract between me and MEGH so as to alter the at-will character of my employment. I further understand and agree that no person at MEGH, other than the President, has any authority to make any promise or representation to alter the at-will character of my employment, raises or an y form of pay.
6)I understand and agree that, if offered employment, such employment shall be subject
to the reasonable rules and regulations of MEGH as issued or changed at any time, without notification.
7)I understand that upon acceptance of employment, I will be required to provide direct care services to my consumer(s) in the home and/or in the community for the hours that I am assigned. I understand and agree that in the event that a change to my schedule is necessary once an assignment has been accepted, I must contact my immediate supervisor to request a change in assignment or a schedule modification. *Failure to do so may result in immediate termination.
8)I also understand that as part of The M.E. Green House ongoing commitment to quality assurance and quality care, my consumer(s) may be contacted on a weekly basis to verify that direct care services have been received as scheduled and agreed to by the consumer and the direct care staff.
9)I understand and agree that MEGH may at times require overtime, holiday work, change of hours and/or days I am scheduled to work, or require me to work a schedule other than that for which I was originally hired, and I accept these conditions of my continuing employment.
10)I understand and agree that MEGH may change my job title, assigned duties, wages, benefits, place of employment, and/or other conditions of employment at any time, and I accept these as conditions of my continuing employment. I understand and agree that this is an application for employment and that no employment contract is offered or implied.
Signature:______Date: ______
If application is submitted electronically to agree to terms stated above please type your name and date in the box below.