Certified Nursing Assistant (CNA) /Clinical Secretary

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Certified Nursing Assistant (CNA) /Clinical Secretary - PRN

Sparta, North Carolina, United States | Inpatient Nursing Services (003) | Part-time

Apply by: No close date

Application Form

First Name *

Middle Initial

Last Name *

Preferred Name

SSN *

Email Address *

Address *

City *

State *

Zip *

Primary Phone Number *

Alternate Phone Number 1

Alternate Phone Number 2

Best Way to Contact *

Best Time to Contact *

What is your highest level of education? *

What school did you attend? *

Did you graduate? *

What skills could you bring to Alleghany Health? *

Do you have state licensure for this position? *

Licensure Name

Licensure Number

Licensure Issue Date

Licensure Expiration Date

Have you ever had any action taken against your professional license?

If you answered "yes" to the question above, please explain the circumstances/outcome.

How many years of experience do you have relating to this job title? *

Are you currently employed? *

Work History 1: Name of company

Work History 1: Name of Supervisor

Work History 1: Dates of Employment

Work History 1: Employers Phone Number

Work History 1: Job Title

Work History 1: Hourly Pay/Salary

Work History 1: Describe your job duties.

Is this a Full-Time position? *

Work History 2: Name of company

Work History 2: Name of Supervisor

Work History 2: Dates of Employment

Work History 2: Employers Phone Number

Work History 2: Job Title

Work History 2: Hourly Pay/Salary

Work History 2: Describe your job duties?

Was this position Full-Time (FT)? *

Work History 3: Name of company

Work History 3: Name of Supervisor

Work History 3: Dates of Employment

Work History 3: Employers Phone Number

Work History 3: Job Title

Work History 3: Hourly Pay/Salary

Work History 3: Describe your job duties?

Was this position Full-Time? *

Were/Are you a member of the U.S. Armed Forces?

If yes, describe your experience such as branch, rank and type of discharge along with years served.

Minimum Salary Desired *

When will you be available to begin work? *

How did you find out about this position? *

If you were referred by a current employee, enter their name and department

What schedule/shift would you accept? *

As needed
Part-Time
Full-Time

Do you have any relatives currently employed by Alleghany Health and its affiliates? *

If you answered "yes" to the above question what is the employees name/department/relationship to you?

If you are under 18 years of age, can you provide required proof of your eligibility to work? *

Are you legally eligible for employment in the United States? *

If you answered "yes" to the above question and you are not a U.S. citizen, please provide the number of your Resident Alien or Work Authorization Card

Alleghany Health is a smoke-free campus. Will you be able to comply with this policy? *

Have you ever been employed by Alleghany Health? *

If you answered "yes" to the above question what was your hire date and department? Indicate if you had a different name while employed. *

Were you referred by an Alleghany Health Employee? Answer, yes or no and if yes, please enter the employee name. *

Do you have an limitations that would affect your ability to perform the essential job functions of your position(s)? *

If you answered "yes" to the above question, please explain.

May we conduct a detailed reference check? *

If you answered "no" to the above question, please indicate any employers you do not want us to contact.

Are you charged with an unresolved criminal charge? *

If you answered "yes" to the above question, please explain fully.

Have you ever been sanctioned by or excluded from participation in Medicare, Medicaid or any government health program? *

Are you currently under investigation for sanctioned issues? *

Will you be willing to take a pre-employment physical? *

Will you be willing to take a drug-screening test? *

References (3 required ; Include name, phone number or email) *

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