Application for Employment
Please Read Before Filling Out This Application for Employment
Below is a checklist of documentation needed to complete the application for employment. You should plan to assemble your documentation prior to filling out this form. Once you press the submit button at the bottom of the page and your answers meet all system validation requirements, you will no longer be able to update this form. Please read through this page in its entirety to make sure you have gathered all the relevant information.

Documentation Checklist
  • Employment History
  • References
  • Cover Letter (Optional)
  • Resumé (Optional)

Application for Employment

The Medical Mutual Insurance Company of North Carolina and it's subsidiaries (hereafter represented as "Company") does not discriminate in hiring on the basis of race, color, sex, religion, national origin, age, disability, or veteran status.  No question on this application is intended to secure information to be used for such discrimination.  Upon request, the Company will provide reasonable accommodations to qualified individuals with disabilities provided they do not pose an undue hardship on the business.

We intend 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.

Position Applying for
Position *
Referral Source
Referral List *
Please specify:
First *MiddleLast *
Street  *
Street/Apt #
City *
State *
Zip *
Personal Data
Other names you have been know by,
including maiden name.
If none, enter N/A.
(100 character limit)
Are you 18 years or older? *
Telephone Number *
Email Address
Please re-enter your email address:
Valid Drivers License No. *
Drivers License State of Issue *
Drivers License Date of Issue *
May we contact you at work? *
Are you authorized to work for any employer in the US? *
If hired, can you provide proof that you are eligible to
work in the US? *
Will you now, or in the future, require sponsorship by the
company to retain employment in the US? *
If so, please explain.
Have you ever plead guilty or been convicted of a crime
other than a minor traffic violation? Do not include sealed
and expunged convictions.  *
If yes, please explain. (A "yes" answer to this question does not necessarily preclude consideration for employment. )
Educational Data
 Name of SchoolCity & StateMajor Subject
or Course of Study
GraduatedYears CompletedDegree Received
High School
Graduate School
Business or Trade
Date you can start *
Salary desired *
      Pay frequency *
Are you currently employed? *
May we contact your present employer?
Do you have an Employment Agreement and/or
Non-Competition Agreement with your current or
past employer?
Have you ever applied here before? *
Please provide job title(s) and date(s). (500 character limit)
Have you ever been employed by the company? *
Please provide job title(s) and date(s). (500 character limit)
Work History
List the most recent first. All periods of unemployment (longer than 60 days) should be shown in a separate block.
The following information must be supplied in full even if you attach a resume.
CompanyAddress (100 character limit)PositionSupervisorPhoneRate of Pay
Rate of Pay
Reason for Leaving
Military Service
Military StatusActive Duty fromActive Duty toBranch of Service
Skills and Qualifications
Summarize any special training, professional membership, skills, honors, awards, publications, licenses
and/or certifications that may qualify you as being able to perform job-related functions in the
position for which you are applying. (approximately 1000 character limit)
Summarize special skills and qualifications acquired from employment or other experience, including
software applications you are skilled in using. (approximately 1000 character limit)
Relatives/Acquaintances in Our Employment
 NameOccupationYears KnownPhoneAddress
Cover Letter
(Optional) Copy/Paste the contents of your Cover Letter here (approximately 10,000 character limit):
(Optional) Copy/Paste the contents of your Resumé here (approximately 20,000 character limit):
Application Form Disclaimer

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefits plans, policy statements, and the like as they may exist from time to time, or other Company practices shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Company, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned.  Both the undersigned and the Company, may end the employment relationship at any time, without specific notice or reason.  If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.

I authorize  investigation of all statements contained in this application. I understand that misrepresentation or omission of facts may be cause for dismissal at any time without any previous notice.  I authorize the investigation of all matters contained in this application and hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contact.

I also understand that the Company will employ only those individuals who are legally authorized to work in the United States and who present acceptable proof of their lawful employment status and identity, and that any offer of employment is conditional upon the completion of the verification process required by the Immigration Reform and Control Act of 1986.

The Fair Credit Reporting Act requires us to advise you that, in connection with our routine processing of your employment application, we may request from a consumer reporting agency an investigative consumer report including information as to your character, general reputation, personal characteristics, mode of living, and motor vehicle operating records.  Upon written request from you, we will provide you with additional information concerning the nature and scope of any such report requested by us.

If employed, I agree to abide by the employment policies, practices, and procedures of this Company, to obey safety and work rules, and to conduct myself in a manner that conforms to the standards of conduct required of Company employees.  I further understand that my employment with Company shall be probationary for a period of ninety (90) days, and further that at any time during the probationary period and thereafter, my employment relation with the Company is terminable at will for any reason by either party.

The Company is an equal employment opportunity employer.  We adhere to a policy of making employment decisions without regard to race, color, religion, sex, national origin, citizenship, age, disability, veteran status, genetic information or any other status or condition protected by current federal or state regulations.  We assure you that your opportunity for employment with this Company depends solely on your qualifications.

Thank you for completing this application.