Granville Health System Volunteer Application

Full name

Date

Street Address

City

State

Zip

Telephone Number

Cell Phone Number

Email

Are you 18 years of age or older?

Yes

No

Have you lived in North Carolina the last 5 consecutive years?

Yes

No

How did you learn of this opening? [website, walk-in, employee referral (name)]

Have you ever volunteered or been employed here before?

Yes

No

If you have volunteered or been employed here before, please provide the date and position.

Are there any hours, shifts, or days you cannot or will not volunteer?

Schedule preferred

Part time

Full time

PRN (as needed)

Any

Shift preferred

Any

Days

Evenings/Nights

Education

Please provide school name, location, major, and GED/Diploma/Degree earned for each of the schools you attended.

High School

College 1

College 2

Other Training/Education

Certification/Registration

In addition to your work history, what other experiences, skills, or qualifications do you possess to make you more suitable for our facility?

Positions of Interest

Date available to begin

Prior Employment

(start with most recent employer)

1 - Employer Name

1 - Address

1 - Phone Number

1 - Dates of Employment

1 - Position

1 - Duties

1 - Supervisor's Name

1 - Reason for Leaving

Prior Employment - Employer 2

2 - Employer Name

2 - Address

2 - Phone Number

2 - Dates of Employment

2 - Position

2 - Duties

2 - Supervisor's Name

2 - Reason for Leaving

Prior Employment - Employer 3

3 - Employer Name

3 - Address

3 - Phone Number

3 - Dates of Employment

3 - Position

3 - Duties

3 - Supervisor's Name

3 - Reason for Leaving

Military Service

Branch of Service

Dates of Service

Rank & Duties

Date Discharged

Personal References

1 - Reference Name

1 - Reference Address

1 - Years Known

1 - Reference Phone Number

Personal References

2 - Reference Name

2 - Reference Address

2 - Years Known

2 - Reference Phone Number

Personal References

3 - Reference Name

3 - Reference Address

3 - Years Known

3 - Reference Phone Number

The above information is true and complete to the best of my knowledge. Should I be a volunteer at Granville Health System, any misrepresentation or false statement contained herein may be considered cause for possible dismissal. Granville Health System has my permission to obtain all necessary information from the references I have listed, or any other sources, concerning my prior employment, personal history, and I release all parties from any possible damages resulting from disclosing such information with or without prior written notice to me. I reserve the right to know the names and addresses of any investigative agencies used in order that I may learn the information contained in any reports furnished to Granville Health System. I understand this application does not constitute a volunteer contract of any kind. Should I volunteer at Granville Health System, I may resign at any time at my discretion with or without prior notice and Granville Health System may terminate my volunteer services at any time at their discretion, with or without cause and with or without prior notice. I understand I am applying for a position at a tobacco-free facility that does not permit smoking and the use of tobacco products in the building, on the grounds, or in the parking areas of any owned and leased property of Granville Health System.

If you agree with the above statement, please check "Agree"

Yes

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