Name: LAST FIRST MIDDLE. Address: STREET CITY STATE ZIP

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1 An Equal Opportunity Employer Application for Employment Goshen Medical Center, Inc P.O. Box 187 Faison, NC Please Read Carefully Before Filling Out This Application Phone (910) Fax (910) This, Company does not discriminate in hiring or employment on the basis of race, color, sex, religion, disability, national origin, citizenship, or on the basis of age with respect to persons 18 years or older. No question on this application is intended to secure information to be used for such discrimination. Proof of identity and work authorization will be required upon employment in accordance with federal regulations. This Company intends to check and hold you responsible for the accuracy of the statements you make on this application. This application will receive consideration for thirty (30) days. If you have not heard from the Company within thirty days and wish to receive further consideration for employment, it will be necessary to complete another application form. Personal Data Social Security Number Name: LAST FIRST MIDDLE Are you 18 years or older? Yes No Address: STREET CITY STATE ZIP Telephone Number Address Have you ever been convicted of a felony other than minor traffic violations? (A yes answer to this question does not necessarily prelude consideration for employment) Yes No Education Please Check Highest Grade Completed: Grade, Junior High, or High School College or University Graduate School Type of School Name of School Location Major Course of Study Did you Graduate? Yes ( ) No ( ) High School College Business or Trade School Graduate School List Degrees Obtained:

2 Employment Job applied for Salary desired Are you employed now? If so, may we contact you present employer? Have you ever applied here before? When? Have you ever worked for this Company before? When? Are you available to work any shift? Any day of the week? If not, for what shifts and days are you available? When could you report for work? Work History Period of employment Name & Address of Rate of Positions held or duties performed (Month/Year) Company Pay From: Company: Start: To: Address: Final: Reason for leaving: Period of employment Name & Address of Rate of Positions held or duties performed (Month/Year) Company Pay From: Company: Start: To: Address: Final: Reason for leaving: Period of employment Name & Address of Rate of Positions held or duties performed (Month/Year) Company Pay From: Company: Start: To: Address: Final: Reason for leaving:

3 Relatives in Our Employment Name Relationship Name Relationship Military Branch of Service: Duties in the service, including schools and training: Special Skills What knowledge, special technical or computer skills, and/or other qualifications have you acquired from employment or other experience? Include any specific equipment that you can proficiently operate. List any first aid or emergency response training for which you are currently certified (give date or certification).

4 References Give three references who are not relatives or former employers Name Occupation Years Known Phone Address Statement of Authorization I authorize, without liability, investigation of all statements in this application. I expressly waive all provisions of law prohibiting any physician, person, hospital, or other institution that has or may hereafter attend or furnish me with treatment from disclosing to the Company any knowledge or information hereby acquired. I authorize all schools which I attended and all previous employers to furnish to the Company my record, reason for leaving and all information they may have concerning me, and hereby release them and the company from all liability for any damage whatsoever arising there from. I authorize my neighbors, friends or others with whom I am acquainted or who are acquainted with me to furnish the Company with information used in connection with the evaluation of my qualifications as a prospective employee. I also authorize the making of a credit bureau investigative report whereby information may be obtained concerning my character, general reputation, personal characteristics and mode of living, whichever may be applicable. I understand I will be notified if such an investigation report is obtained and I will have the right to make a written request within a reasonable period of time for a complete and accurate disclosure of information concerning the nature and scope of the investigation. I understand that in event of my employment by the Company, it shall be sufficient cause for dismissal if any of the information I have given in this application is false or if I have failed to give any information herein requested. I understand that proof of identity and work authorization will be required upon employment in accordance with federal regulations. In the event of my employment by the Company, I agree to abide by all present and subsequently issued rules of the Company. Signature: Date:

5 Have you ever pled guilty, pled "no contest", or been convicted of any crime (including a traffic offense) which was not dismissed, annulled, expunged, or sealed by the court -or- are you currently serving probation or experiencing charges pending against you? If yes, give date and details of each situation (add sheet, if necessary) NOTE: Answering Yes to this question does not constitute an automatic bar to employment. In considering you for employment, we will consider the nature and seriousness of the offense(s); the time that has passed since the conviction and/or completion of the sentence: and the nature of the job you are seeking. Falsification of your answers may result in no job offer or dismissal if you are hired. Signature: Date:

6 Goshen Medical Center Inc. is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, Goshen Medical Center Inc. invites employees and applicants to voluntarily self-identify their gender and race/ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information will be kept confidential and will only be used in accordance with the provisions of applicable laws, executive orders, and regulations; including those that require the information to be summarized and reported to the federal government. When reported, data will not identify any specific individual. We invite you to provide the information requested below. You need only check the one box that most clearly describes your gender and racial/ethnic background. Again, participation is STRICTLY VOLUNTARY. Failure to provide this information will not subject you to any adverse personnel decisions or actions. Your cooperation is appreciated. GENDER: (Please check one of the options) Male Female RACE/ETHNICITY: (Please check one of the descriptions below corresponding to the ethnic group with which you identify.) Hispanic or Latino A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. White (Not Hispanic or Latino) A person having origins in any of the original people of Europe, the Middle East or North Africa. Black or African American (Not Hispanic or Latino) A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) A person having origins in any of the people of Hawaii. Guam, Samoa or other Pacific Islands. Asian (Not Hispanic or Latino) A person having origins in an of the original people of the Far East, Southeast Asia or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam. American Indian or Alaska Native (Not Hispanic or Latino) A person having origins in any of the original people of North and South America (including Central America) and who maintain tribal affiliation or community attachment. Two or More Races (Not Hispanic or Latino) All persons who identify with more than one of the above five races. HOW DID YOU HEAR ABOUT GOSHEN MEDICAL CENTER, INC.? (Please check one that applies) Newspaper Advertisement Internet Website State Employment Agency Employee Walk-in Other Please Specify:

7 NORTH CAROLINA CAREER READINESS CERTIFICATE GOSHEN MEDICAL CENTER REQUIRES THE CAREER READINESS CERTIFICATE FOR ALL CLERICAL POSITIONS CONTACT YOUR LOCAL COMMUNITY COLLEGE FOR MORE INFORMATION

8 An information brief on the ACT WorkKeys system KEY FACTS The ACT National Career Readiness Certificate and job requirements Two decades of collecting data generated by the ACT WorkKeys assessment system contributes to unique ACT data sets. ACT JobPro, ACT s proprietary database of occupational information, represents a one-of-a-kind repository of data describing the tasks, skills, and skill requirements established by more than 19,000 job analysis studies. The common language of the ACT WorkKeys system creates linkages between ACT JobPro and the abundant examinee data produced by administering more than 24 million ACT WorkKeys assessments. The ACT WorkKeys assessment system measures job skills that are valuable for any occupation skilled or professional at any level and in any industry. Linking these data sets creates a unique perspective on skill supply-and-demand forces within the workforce, one that is useful to individuals, employers, workforce and economic developers, and policymakers. ACT data also help individuals connect with jobs, enable employers to identify qualified applicants, facilitate standards for jobs and training programs, and serve as an indicator of career and work readiness. The multilevel ACT National Career Readiness Certificate (ACT NCRC ) is based on the ACT WorkKeys system and its linked data sets. These relationships often lead to such questions as how does an ACT NCRC level relate to skill requirements? The ACT National Career Readiness Certificate is an industry-recognized, portable, evidence-based credential that certifies achievement of foundational skills essential for workplace success. About O*NET The Occupational Information Network (O*NET) is an electronic portal used to access occupational information generated by federal agencies. Different employers often identify the same job with different titles; to remedy this, every job profile is assigned a code that links it to an O*NET occupation and, by extension, to data and information that pertain to it. Current job profiles address the skills for 549 of the 974 occupations listed by O*NET. Qualified for vs. meets skill requirements What jobs are ACT NCRC holders qualified for? Individuals who have earned the ACT NCRC have demonstrated that they have the core foundational skills to be successful in a job. Individuals with a Silver ACT NCRC, for example, have the essential foundational skills needed for 69% of jobs. Determining the precise number of jobs for which an ACT NCRC recipient has the skill requirements is challenging for a number of reasons, including: ACT JobPro organizes task, skill, and skill level information in terms of O*NET occupations. Multiple profiles have been completed for most of them. The ACT NCRC level is determined by the lowest score its recipient achieved on Applied Mathematics (AM), Reading for Information (RI), and Locating Information (LI). This means that many combinations of scores are associated with the same certificate level. For example, a Bronze ACT NCRC is issued for combinations of scores that include 3(AM)-3(RI)-3(LI), 3-4-3, 3-4-4, 4-4-3, 5-3-5, 3-5-3, 3-3-5, and many others. Skill requirements for occupations listed in ACT JobPro can be expressed as more than 100 different combinations of scores achieved on the three assessments supporting the ACT NCRC by ACT, Inc. All rights reserved

9 Key Facts The ACT National Career Readiness Certificate and job requirements Some occupations listed in ACT JobPro do not require the three assessments associated with the ACT NCRC. This is because related job profiles concluded that other ACT WorkKeys skill areas are more essential to performing the tasks these occupations require. Only ACT NCRC levels, not the actual scores achieved on the assessments, are listed on the ACT NCRC. Responding to the question of qualified for A conservative approach can be used to estimate the number of jobs and percentage of profiled jobs for which a certificate recipient is qualified, based on possessing the essential foundational skills. An ACT WorkKeys score indicates the ability to perform skills associated with a specific skill level and all of the levels that precede it: a Level 6 score on Reading for Information reports the ability to perform skills that are associated with Level 6, as well as Levels 3 5. KEY TAKEAWAY The question of which jobs an individual who has earned the ACT NCRC is qualified to perform is difficult to answer, due to many variables. Rather than qualified for, the key is to address how the core skill levels achieved meet job skill requirements. For example, an individual with a Silver ACT NCRC has the essential foundational skills required by 69% of jobs. A Platinum ACT NCRC requires minimum scores of Level 6 on three assessments, so the individual who earns this credential would meet the score requirements for any job requiring scores of Level 6 or lower in Reading for Information, Applied Mathematics, and Locating Information. Similarly, the recipient of a Gold ACT NCRC would qualify for all occupations requiring scores of Level 5 or lower in these three ACT WorkKeys skill areas. This approach yields the breakdown below by certificate level. Jobs are O*NET-defined occupations identified in ACT JobPro. At least one profile for each occupation was performed between 2007 and 2011 and the profile(s) identified the three ACT NCRC skills as essential. The table to the right should be interpreted as showing that individuals with a Silver ACT NCRC have the essential foundational skills needed for 69% of jobs. ACT National Career Readiness Certificate The ACT NCRC is a portable, evidence-based credential that certifies foundational skills essential for workplace success. This credential is used across all sectors of the economy and verifies the following cognitive skills: Problem solving Critical thinking Reading and using work-related text Applying information from workplace documents to solve problems Applying mathematical reasoning to work-related problems Setting up and performing work-related mathematical calculations Locating, synthesizing, and applying information that is presented graphically Comparing, summarizing, and analyzing information presented in multiple related graphics ACT NCRC level Percentage of jobs 99% 93% 69% 17%