Registered Nurse Part Time

APPLICATION FOR EMPLOYMENT

State of North Carolina

Instructions to Applicants

TO BE CONSIDERED FOR STATE EMPLOYMENT, YOU MUST ANSWER ALL QUESTIONS AND

COMPLETE ALL SECTIONS OF THIS APPLICATION FORM.

THE STATE EMPLOYS ONLY US CITIZENS OR ALIENS WHO CAN PROVIDE PROOF OF

IDENTITY AND WORK AUTHORIZATION WITHIN 3 WORKING DAYS OF EMPLOYMENT MALES

SUBJECT TO MILITARY SELECTIVE SERVICE REGISTRATION MUST CERTIFY COMPLIANCE

TO BE ELIGIBLE FOR STATE EMPLOYMENT (G.S. 143B-421.1). SEE AVAILABILITY

BLOCK.

WHEN COMPLETING THIS APPLICATION, PLEASE MAKE SURE YOU

. COMPLETE THE SECTION FOR EQUAL OPPORTUNITY INFORMATION.

. APPLY FOR ONE VACANCY PER APPLICATION.

. IF YOU ARE A RIF APPLICANT WITH PRIORITY- PLEASE CHECK THE APPROPRIATE

BOX.

. GIVE COMPLETE INFORMATION ON YOUR EDUCATION AND WORK HISTORY ("SEE

RESUME" IS NOT ACCEPTABLE).

. LIST SEPARATELY EACH JOB HELD AND YOUR DUTIES FOR EACH POSITION WHEN

YOU WORKED FOR ONE EMPLOYER AND HELD MORE THAN ONE POSITION.

. AS YOU DESCRIBE YOUR WORK HISTORY, MAKE SURE YOU HIGHLIGHT YOUR

COMPETENCIES (KNOWLEDGE, SKILLS, ABILITIES AND WORK BEHAVIORS) WHICH

DEMONSTRATE YOUR QUALIFICATIONS FOR THE POSITION FOR WHICH YOU ARE

APPLYING.

. PROVIDE ONLY THE LAST FOUR DIGITS OF YOUR SOCIAL SECURITY NUMBER.

. CHECK FOR ACCURACY, SIGN AND DATE YOUR APPLICATION.

THANK YOU FOR YOUR INTEREST IN STATE GOVERNMENT. NORTH CAROLINA WANTS TO

FIND THE BEST QUALIFIED PEOPLE AVAILABLE TO SERVE ITS CITIZENS. ALTHOUGH

EVERYONE WHO APPLIES CANNOT BE HIRED, YOUR APPLICATION WILL BE GIVEN EVERY

CONSIDERATION.

PD 107 (REV 06/2009)

Equal Opportunity Information

State Government policy prohibits discrimination based on race, sex, color, creed,

national origin, age or disability. Sex, age or absence of disability is a bona

fide occupational qualification in a small number of State jobs. The information

requested below will in no way affect you as an applicant. Its sole use will be to

see how well our recruitment efforts are reaching all segments of the population.

Date of Birth DISABILITY: "Disability means, with respect to an individual:

(1) a physical or mental impairment that substantially limits

(Month) (Day) one or more of the major life activities of such individual; (2)

(Year) a record of such an impairment; or (3) being regarded as having

such an impairment" (Americans with Disabilities Act of 1990).

Gender Persons without a disability should check item A.

The reporting of a disability is strictly VOLUNTARY. Persons

Male with disabilities who DO NOT WISH to report their disabilities

Female should check item A. Information reported on this form will be

kept confidential as required by State law. Public disclosure

of this information without your consent would be a violation of

G.S. 126-27.

ETHNIC GROUP A None/Prefer not to G Respiratory impairment

1. White (non-Hispanic) report H Nervous

2. Black (non-Hispanic) B Blind or severely system/Neurological

3. Hispanic (Mexican, Puerto visually disorder

Rican, Cuban, Central or impaired I Mentally restored

South American, other Spanish C Deaf or severely hearing J Mental retardation

origin regardless of race) K Learning disability

4. Asian (including Pacific impaired L Others (heart disease,

Islander) D Loss of limited use of diabetes,

5. American Indian arms speech impairment)

(including and/or hands M Other (please specify)

Alaskan native) E Non-ambulatory (must use ______________________

wheelchair)

F Other orthopedic

impairment

(including amputation,

arthritis,

back injury, cerebral

palsy, spina

bifida, etc.)

APPLICATION FOR EMPLOYMENT STATE OF Date of

NORTH CAROLINA Application

Last 4 digits of Last Name First Name Middle Name

Social Security No.

Address (Street number and name) City County

State Zip Code Phone (Home or where Business Phone

you can be reached)

Availabili

ty Are you a layoff candidate with the State of N.C. If subject to

Do you now eligible for RIF priority reemployment consideration Military Selective

work for as described by GS 126: YES NO Notification Service

the State Date:___________________ registration,

of NC? Are you related by blood or marriage to any person certify compliance

YES NO now working for the State YES NO by initialing

If yes, give name, relationship to you and the dotted line

agency where employed.

Military Service

Have you served honorably in the Armed Forces of the United States on active duty

for reasons other than training? YES NO

Do you wish to declare a service-connected disability? YES NO

At the time of this application, are you the surviving spouse or dependent of a

deceased veteran who died from service-related reasons? YES NO

Do you wish to declare eligibility for veterans preference as the spouse of a

disabled veteran? YES NO

Give dates of your (or spouse's) qualifying active military service:

Entered: Separated: Branch: Rank

AGENCY USE ONLY: ELIGIBILITY FOR VETERAN'S PREFERENCE: YES NO

CHECK the types of work you will accept: 1. Permanent full-time 2. Permanent

part-time 3. Temporary full-time 4. Temporary part-time 5. Any of the

preceding 6. Work involving Travel 7. Shift or Split Shift Work

If you are not available for work now, enter the earliest date you could begin work

(mo/day/yr.)

Will you accept work anywhere in N.C.? YES NO (If no, list below the counties

in which you would be willing to work.)

1. 2. 3. 4. 5.

Job Applied For

Enter below the specific title and vacancy number of the job for which you are

applying.

Job Title: Vacancy Number:

Referral Source

Please indicate your referral source:

If you were referred by the Employment Security Commission (Job Service) please

indicate which local office:

Education

Circle highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12 GED

College 1 2 3 4 Graduate School 1 2 3 4

Under S/Q Hrs., list the hours of credit received and if they were semester (S) or

quarter (Q) hours.

Dates Attended Type of

Schools Name and Location (mo/yr) Grad? S/Q Major/Minor Degree

From: To: Hrs. Course Work Receive

d

YES

High NO

School

Graduate YES

or NO

Profession

al

Other YES

educationa NO

l,

vocational

school,

internship

s, etc.

Special training programs and seminars you have completed in the last five years

(list):

If the job(s) applied for calls for specific courses, indicate those courses taken

and credits received:

Current professional status: (List fields of work for which you have been

registered)

Registration: State: No.

Registration: State: No.

Membership in professional, honorary, or technical DO NOT COMPLETE THIS BLOCK

societies (list): DEGREES AND PROFESSIONAL

CREDENTIALS

Have been verified

Will be verified within 90 days

(G.S. 126-30)

Person Responsible:

Licenses and certifications (List, giving dates and sources of issuance):

REGISTERED NURSE-9/1997 NC

SKILLS

CHECK the following skills, experiences, etc., which you have:

Driver's License 5584122 Sign Language Legal transcription

NC Foreign language (specify) Medical transcription

Number State Braille

Chauffeur's License N/A Adding Machine/calculator Word Processing

Typing (specify WPM) Other

Number State Shorthand/speedwriting

Car for use at work (specify WPM)

Have you ever been convicted of an offense against the law other than a minor

traffic violation? (A conviction does not mean you cannot be hired. The offense

and how recently you were convicted will be evaluated in relation to the job for

which you are applying.) YES NO (If yes, explain fully on an additional

sheet.)

WORK HISTORY (include volunteer experience) Use additional sheets if necessary.

As you describe your work history experiences, make sure you highlight your

competencies which demonstrate your qualifications for the position for which you

are applying.

Current or Last Employer: Address:

CENTRAL REGIONAL HOSPITAL 300 VEAZEY ROAD BUTNER,NC 27509

Job Title: Supervisor's Telephone Number No. Supervised

PROFESSIONAL NURSE Name by you:

Mary Lou Leah 764-2581 3-6

Date Employed Starting Ending or Reason for May We Contact

(mo/yr) Salary Current Salary Leaving Employer

11-2007 $30.00 per $30.00 per hr. Perm. W/E Plan YES NO

Date Separated List major duties that demonstrate your competencies related to

(mo/yr) the position for which you are applying in order of their

Present Employer importance in the job:

Full Time Years Medication/treatment Administration,Assessment &

Months Charting,Vertifying

2 9 Orders,Phlebotomy,Accu-checks,VS,-Intervention for illness

Part Time Years and injury and routine health care,monitoring the health

Months and safety of patients,de-escalation techniques,1:1

n/a Observations,Seclusion / Restrainst Protocol, Delegating task

If part time, to LPN'S and HCT's and rotating charge role. Currently,

number of hours working on CAU -DAY BAYLOR POSTION.

worked per week:

Employer: Address:

Dorothea Dix Hospital 501 South Boylan Ave. Raleigh,NC 27610

Job Title: Supervisor's Telephone Number No. Supervised

Registered Nurse B Name by you:

D. Jeter 919-***-**** 3-6

Date Employed Starting Ending or Reason for Leaving

(mo/yr) Salary Current Salary Day Baylor position

4-2006 $28.00 per $30.00 per hr.

Date Separated List major duties that demonstrate your competencies related to

(mo/yr) the position for which you are applying in order of their

10-2007 importance in the job:

Full Time Years Medication Administration,Assessment, Intervention, and

Months Evaluation for Illness and Injury,providing routine health

1 7 care,monitoring patient behavioral modifications, delegating

Part Time Years tasks, verifying orders,VS, accu-checks, charting,1:1

Months Observations,Suicide precautions,Seclusion /Restrainst

n/a protocol,and rotating charge nurse role.

If part time,

number of hours

worked per week:

Employer: Address:

Federal Medical Center Old NC. HWY 75 Butner,NC 27509

Job Title: Supervisor's Telephone Number No. Supervised

STAFF NURSE Name by you:

N/A 919-***-**** 2

Date Employed Starting Ending or Reason for Leaving

(mo/yr) Salary Current Salary Flexible hours

3-2005 $26.00 per $28.00 per hr.

Date Separated List major duties that demonstrate your competencies related to

(mo/yr) the position for which you are applying in order of their

4-2006 importance in the job:

Full Time Years Medication Administration, treatments, assessments,IV push

Months meds., venipunture, foley placement and care, trach care,

1 1 PICC line care,tube feeding, wound

Part Time Years care,ABT,VS,Accu-checks,pain management,charting, verti-

Months fying orders,and making rounds with MD.

n/a

If part time,

number of hours

worked per week:

I certify that I have given true, accurate and complete information on this form to

the best of my knowledge. In the event confirmation is needed in connection with

my work, I authorize educational institutions, associations, registration and

licensing boards, and others to furnish whatever detail is available concerning my

qualifications. I authorize investigation of all statements made in this

application and understand that false information or documentation, or a failure to

disclose relevant information may be grounds for rejection of my application,

disciplinary action or dismissal if I am employed, and (or) criminal action. I

further understand that dismissal upon employment shall be mandatory if fraudulent

disclosures are given to meet position qualifications (Authority: G.S. 126-30,

G.S. 14-122.1.)

Signature of Applicant (unsigned applications will not be Date

processed)

Contact this candidate