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La Casa Family Health Center Print-Friendly Employment Application (EN / PDF)

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Personal Information

First Name *

Last Name *

Address *

City *

Zip *

How long at current address? *

Contact Information

Applicant's Main Phone *

Applicant's Second Phone

Applicant's Email *

Work Information

Insert Position Name *

Employment Start Date *

Job Type *

Full Time

Part Time

Salary Desired Per Month *

Location(s) Applying For *

Are you related to a Board Member or current employee? *

If yes,who?

High School

High School Name *

High School Address *

High School City *

High School State *

High School Degree Major *

High School Start Date *

d/m/Y

High School End Date *

d/m/Y

High School Zip Code *

Undergraduate School

Undergraduate School Name

Undergraduate School Address

Undergraduate School City

Undergraduate School State

Undergraduate School Degree Major

Undergraduate School Start Date

d/m/Y

Undergraduate School End Date

d/m/Y

Undergraduate School Zip Code

Graduate School

Graduate School Name

Graduate School Address

Graduate School City

Graduate School State

Graduate School Degree Major

Graduate School Start Date

d/m/Y

Graduate School End Date

d/m/Y

Graduate School Zip Code

Technical Knowledge

Technical/Trade School Name

Technical/Trade School Address

Technical/Trade School City

Technical/Trade School State

Technical/Trade School Degree Major

Technical/Trade School Start Date

d/m/Y

Technical/Trade School End Date

d/m/Y

Technical/Trade School Zip Code

Special Skills and Licenses

Special Training/Special Skills

Certifications / Licenses

Technology

Do you have experience with typing? *

WPM

10-Key

Other

Skills

Do you have a personal computer?

Word Processing

WPM

Foreign Language's

Speak:

Write:

Read:

Employment History

Employer 1

Name

Job Title

Address

City

Zip Code

State

Start Date

d/m/Y

End Date

d/m/Y

Employer 2

Name

Job Title

City

Zip Code

State

Start Date

d/m/Y

End Date

d/m/Y

May we contact your present employer? *

After reviewing the attached job description, please indicate if you are able to perform the essential functions of the job for which you have applied *

If you answered “No”, please identify those job functions that you cannot perform. If a reasonable accommodation is required to enable you to perform the job properly and safely, please describe:

Transportation

Do you have a driver’s license? *

What is your means of transportation to work?

Driver’s license #

State of Issue

Expiration Date

d/m/Y

Operator

Commercial (CDL)

Have you had any accidents during the past three years? *

How many?

Have you had any moving violations during the past three years? *

How many?

References

References One - Name *

Reference One -Title *

Reference One - Years of Acquainted/Relationship *

Reference One - Phone Number *

Reference One - Email *

Reference One - Address *

Reference One - City *

Reference One - Zip Code *

Reference One - State *

Service Record

Branch of Service

Discharge Date

d/m/Y

Rank

Optional: Resume

Upload Resume

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Conviction Verification

Have you ever been convicted or plead no lo contendre (no contest) of a violation of any law or ordinance in this state or elsewhere? *

Have you had a conviction set aside or adjudicated? *

If yes, explain each conviction, setting forth the date, charge, court and action taken:

Upload Conviction Explanation Letter

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Application Form Waver

In exchange for the consideration of my job application by La Casa Family Health Center, I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relations, either in the position applied for or any other position, and regardless of the contents or employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time of time, or other La Casa Family Health Center practices, shall serve to create an actual or implied contract or employment, or to confer any right to remain an employee La Casa Family Health Center, or otherwise to change in any respect the employment-at-will relations between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the Chief Executive Officer of La Casa Family Health Center. Both the undersigned and La Casa Family Health Center may end the employment relationship at any time, without specified notice or reason. If employed, I understand that La Casa Family Health Center may unilaterally without specified notice or reason. If employed, I understand that La Casa Family Health Center 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 the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give La Casa Family Health Center permission to contact schools, all previous employers (unless otherwise indicated), references, and others, and hereby release La Casa Family Health Center from any liability as a result of such contact.

I understand that, in connection with the routine processing of your employment application, La Casa Family Health Center will require a pre-employment drug screen.

I understand that, in connection with the routine processing of your employment application, La Casa Family Health Center will conduct a background check.

I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

I further understand that my employment with La Casa Family Health Center shall be probationary for a period of one hundred and eighty (180) days, and further that at any time during the probationary period or thereafter, my employment relationship with La Casa Family Health Center is terminable at will for any reason by either party.

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Signature *

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